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Applications Will Be Pr d eased When Submitted Properly Completed.Be Sure To Sign TheApplication. ,L ,) ?► <br /> FOR OFFICE USE: APPLICATION <br /> D (f=or Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtjora permit to construct and/or installthework herein described.This application is <br /> made in compliance wit n Joaq n Count r ina ce No.18E2:and the rules and regulations of the San J u' l� iltr f3�strict. <br /> u City/Town r U�) <br /> Exact Site Address <br />- � ";:� Phone <br /> Owner's Name � C, <br /> Address ^' '' City <br /> Contractor's Name C !" License#MTP% Business Phone <br /> Contractor's Address W 019' Emergency Phone f <br /> Is Certificate of Workman' Compensation insura a on File With SJLHD? Yes No <br /> Workman's <br /> TYPE OF WORK'(CHECK) -NEW WELL`-IDEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 'OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> REPLACEMENT <br /> ❑ t <br /> R f <br /> DISTANCE TO NEAREST: Septic Tank IN Sewer"Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> f Property Line_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL S <br /> ❑KINDTRIAL + 1:1 CABLE TOOL � -Dia. of Well Excavation <br /> ! ❑ DRILLED Dia. of Well Casing <br /> STIC/PRIVATE STIC/PUBLIC ❑ DRIVEN Gauge of Casing — <br /> ❑,IRRIGATION ❑ G L PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL . I Surface Seal Installed By: vv <br /> PUMP INSTALLATION: Contractor <br /> _. Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: _ ❑ State Work Done <br /> DESTRUCTION OF WELL: ~'Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County <br /> l� ordinances, state-laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the pertormance of the work for which th is permit <br /> • , F# is issued, I sfiall not employ any personin.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 thework for which this 4 <br /> permit is issue Yl s II Joy p ons subject to workman's compensation laws of California." - � <br /> I w' to p o rior to grouting and a final in on. <br /> Signed-Xy Title: <br /> I {� �Y//}y 'Date- <br /> (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE"ONLY L <br /> I PHASE I te r. 7 <br /> "Application Accepted By ! Da <br /> a <br /> iI ''Additional Comments: <br /> t <br /> ase Grout Inspection Phase III Final Inspection <br /> ' h <br /> s e'eer.f" .Date r <br /> ` �,.u� Date� L inspection By— � <br /> Inspection By , <br /> l _ .� 1. Sa-Saa <br /> i <br /> January 31 July 1 &Received By July 31 <br /> .Flee Is Due: ❑"ANNUALLY ❑-PER UNIT ❑ PER SITE ❑ EACH?"D January 1,&Received By ❑ <br /> REMIT s <br /> ' BASE: 1�EXPLANATION BILLING F REMITTANCE_ $ - ---AMOUNTDUE CHECKED <br /> DATE € DATE REMITTED AMOUNT <br /> FEE•t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ° <br /> OTHER <br /> ' � f i _� ,CSS•�'. <br /> CJ` ssuance ate Nailed Delivered <br /> -Received by Date --"_---Receipt No-'-.� W^ Permit No.-- ---•- - - <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL WEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O_Box 2009 STOCKTON,CA 95201 <br />