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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureTaj;lgn IneAppncauon. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) 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 Joaquin County Ordinance No. 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address cG tri City/Town � d <br /> Owner's Name •gR� Phone <br /> Address City '�✓"\�" <br /> Contractor's Name �^^ �9 .'Ta <br /> �-�---- License# Bus ess Phone 2O^4JE <br /> Contractor's Address (L_ - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT P <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> tT <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 /> R 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 ee Surface Seal I stalled By: <br /> PUMP INSTALLATION: Contractor 1��` cJ�lt�� �l gill. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: R 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." 6 P-4 <br /> 1 M'Ilallfora '--��'"ut inspection prior to grouting and a final inspection. _4Y���� �,f�,� <br /> Signed XTitle: Date: 1�9 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY O IS- <br /> l/✓ S. Dy <br /> PHASE I <br /> Application Accepted By Date A <br /> Additional Comments: <br /> Phase II Grout Inspection P ase 111 Final Inspection J <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 July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �3 7a- G <br /> Received by bate Receipt No. Permit No. Is ante bate Mailed Delivered <br /> APPLICANT—RETUflN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON�5 1 <br />