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pPnmanonswm t3eProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. — <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WE'LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uinn County Ordinance No. 1862 and the rules and regulations of the SLocal Health District" <br /> Exact Site Address y r' -I an Joaquin f o <br /> rJ011- e City/Town <br /> Owner's Name c >Y* �s <br /> Address <br /> Phone_ <br /> City eL <br /> Contractor's Name <br /> License Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes fes' No' <br /> TYPE OF WORK (CHECK): NEW WELL®___ DEEPEN ❑ RECONDITION[] ,, DESTRUCT ON❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q" OTHER"0 ' PUMP INSTALLATION ❑ PUMP REPAIR 0' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST:_ Septic Tank Sewer"Lines � Q <br /> pit Privy <br /> �� <br /> Sewage Disposal Field f' Cesspool-Seepage Pit <br /> Other <br /> Property Lin ` Dp ' •private Domestic4�ilell Public Domestic Well <br /> INTENDED USE <br /> TYPE-OF WELL <br /> ❑ INDUSTRIAL = CABLE.TOOL f �jL <br /> t ation <br /> Dia. of Well Excav <br /> DOMESTIC/PRIVATE ❑ pRILLED "� Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN '- 3 <br /> ❑ Gauge of Casing <br /> IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 13 DISPOSAL Type of Grout<<fCA <br /> 'r <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: rs c6 <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: '� <br /> 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 /> 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, 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 will call for a Gr ut Inspection prior to grouting and a final inspection. `-+- <br /> r <br /> Signed X Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I R DEPARTMENT USE ONLY <br /> Application Accepted By DatQ"E. �+F-- <br /> Additional Comments: <br /> Phase II Grout Inspection / G P Final ction <br /> Inspection By Date 6�/ 1! <br /> Inspection By � to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July i Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED OUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -71 by Dafe Receipt No. Permit No. Issuance Date Mailed Deliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTDN AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />