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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 1 <br /> 4` (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ` ENVIRONMENTAL HEALTH PERMIT <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo�all Health District. <br /> Exact Site Address '=a' Plata O!" .'2,0') �•— City/Town Cf zG h, <br /> Owner's Name -�� / Phone "' <br /> Address !! City <br /> Contractor's Name -L License# /%1®71'04"'Business Phone T1 2 — 7G .7 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes 'K No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ �_1i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR Z <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other m r <br /> Property Line 5 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 ❑iDRIVEN Gauge of Casing <br /> IRRIGATION IT GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done Z' <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 A <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t <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 will call for a Grout Inspecp 'oro ut'ing an a final-inspection. i <br /> . 1 4 <br /> Signed X Title: °+ ' Date: <br /> (Draw PI Plan on Reverse Side) <br /> x <br /> For DEPARTMENT USE ONLY � f <br /> PHASE 1 _ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout IA nspection I Phs06 ial Inspection /� v <br /> r 7 � <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 `❑ July 1 &Received By <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION pp7E DATE REMITTED AMOUNT DUE CHECKED. <br /> AMOUNT <br /> a <br /> FEE <br /> LESStl r4-9 <br /> PRORATION 3 r � y{ � <br /> PLUS G ✓ Z`+ 4 a✓-�a "v } <br /> PENALTY JJ11 <br /> OTHER .`vt <br /> t_ U f <br /> OTHER t1' �t ' i} rr ltir`1l .r „ <br /> �. - 51o`r <br /> Received by Date - Receipt No Permit No issuance Date Mailed Delivered . <br /> .., <br /> APPLICANT—RETURN ALL COPIES TO:'----ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, <br />