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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign_The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 11 (For Non-Transierable, Revocable, Suspendable) ' <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin,Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County rdinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. } <br /> Exact Site Address_ Q-r`n � e �����,9 ��' City/Town <br /> Owner's Name Phone Znv j <br /> Address City <br /> Contractor's Name License#2 Business Phone� _ � <br /> Contractor's Address �3�� �l Emergency Phone r, <br /> Is Certificate of Workman's Compensation Insurance on FIIE,z,ith SJR ? Yes 4f-- No r, <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN W-- RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E�PUMP REPAIR❑ <br /> REPLACEMENT❑ ` f <br /> / l <br /> DISTANCE TO NEAREST: Septic Tank �`_� Sewer Lines Pit Privy <br /> Sewage Disposal Field .2-00 ""—' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 1 .TYPE OF WELL <br /> ❑ INDUSTRIAL 91—CABLE TOOL Dia. of Well Excavation <br /> ❑��DOMESTIC/PRIVATE C3 DRILLED Dia, of Well Casing <br /> MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑' ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urfacee Seal <br /> PUMP INSTALLATION: Contractor L <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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca or a Grout Inspection prior to groutin nd a final inspection. �a <br /> Signed X � � _ "Title: Date: ?a <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By b Date <br /> Additional Comments: <br /> Phase II Gr ut inspection ase 1}I Fi ection �Qr� <br /> Inspection By_ ate Inspection By (t . <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE.-` ❑ EACH ❑ Januar 1 &Received B Januar 31 � <br /> .: Y Y y El 1 &Received By JWy 31" <br /> ' <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT . <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY q <br /> OTHER " <br /> OTHER t ' ..:S.t}..:, <br /> Rec,�ed by Date Receipt No. qY, Permit No. Issuance Date Mailed Delivered <br /> r'"APPLICAN�T-RRETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .'� <br />