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Applications Will Be Processed When Submitted Properly Completed.---Be Sure To Sign The Application. <br /> . .FOR-OFFICE USE: APPLICATION*` £ . <br /> 1 (For Non-Transierable, Revocable, Suspendible) <br /> r � PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co t 0 dI9aDce No. 1862 and the rules and regulations of the San Joa�ujn��al deal h District. <br /> Exact Site Address City/ <br /> Owner's Name ri Phone <br /> Address 011 City <br /> Contractor's Name License Business Phone _52-1 6 <br /> Contractor's Address 4L Emergency Phone 1I. .e <br /> Is Certificate of Workman's Compensation In ranee on File ith'SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL I�� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION Q-' PUMP REPAIR❑ <br /> REPLACEMENT❑ V <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 1-701` Pit Privy <br /> Sewage Disposal Field �' Cesspool/Seepage Pit 19 r10'7 Other ;J <br /> i Property Line, <br /> Private Domestic WeIIPublic Domestic Well <br /> INTENDED USE # TYPE OF WELL <br /> ❑ 5DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE BILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0;<OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information. <br /> ❑ GEOPHYSICAL Surface Sea-I Ile By: <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump rc P <br /> E PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -. - Approximate Depth <br /> 0C'be Material and Proced <br /> I hereby certify that I have prepared this pplication and that the work will be do In actor nee with San Joaquin County <br /> ordinances, state laws, and rules and r ulations of the San Joaquin Local Health District. , <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c It for a Grout Inspection Prior to grouting and a final inspection. <br /> Signed Title: Dale: <br /> { (Draw Plot Plan on Revers ide) <br /> FOR DEPART ENT USE ONLY <br /> PHASE I A� *4 <br /> Application Accepted ByA ` Date 74 <br /> Additional Comments: <br /> Phas HiGr It Inspection L� Q Phase nspection <br /> Inspection By Date 10- •�� • _ Inspection By x Date <br /> Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION � AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE67 <br /> I LESS 7Q <br /> PRORATION <br /> PLUS <br /> PENALTY . <br /> OTHER <br /> OTHER <br /> ` 7 -1-1c�SS 9/19/-79 <br /> Received by Date - Receipt No' Permit No. - - - -Issuance Date -'.�-Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.0.Box 20099, STOCKTON,CA 95201 <br />