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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Anplicalion. <br /> FOR OFFICE USE: ea kw 16VV, APPLICATION <br /> .(For Non-Transferable, Revocable, Suspendable) <br /> " ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COM.pLETE IN TRIPLICATE) �1� ,� �r{/ g11TER QUALITY j'Cr_ 14. -D <br /> Application is hereby made to the San Joaquin Local Health Dist Pict fota permit to construct and/or install the work herein described.This application is� <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /1rG�P i ._ 12r ;r t/ �# 0- If'Nt 110 City/Town <br /> Owner's Name Wim- &x Phone UJ <br /> Address G D ,- G .' City A ' <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WOKS JI HD? Yes X No } <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 7 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® . PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer.Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well �! <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Sal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br />� r <br /> Type of Pump Z41i H.P. 1 �t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done �m,/' <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspec' n prior uttng and a final inspection. <br /> I <br /> Signed X• if <br /> �� Dale: <br /> (Draw PI Ian on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase ill Final IIinspection <br /> Inspection By Date Inspection By Date <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July S &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> Q DATE DATE REMITTED AMOUNT <br /> FEE �N L r Y- <br /> LESS , II <br /> PRORATION ' <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. e—rm A No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P,O.Box 2009 STOCKTON,CA 952 <br />