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y� APP tca Ions Will Be Protease-d When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> OFFICE USE:``' APPLICATION <br /> _ (For Non-Transferable, Revocable, Suspendable) <br /> � WELLWELL PUMP&W� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> P made in compliance with San Joaqui Coun Or di ce No. 1862 a d the rule nd regulations of the San Joa o al Health District. <br /> Exact Site Address f OZ � �l �d4 City/Town <br /> Owner's Name 63I1►�•ri t Phone �d <br /> Address City <br /> a <br /> Con#ractor's Namet6 License.# CjaJ � Business Phone ^ _ <br />? Contractor's Address Emergency Phone <br /> I Is Certificate of Workman's Compensation Insurance on Fil ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPE ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> I REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field ,{Cesspool/Seepage Pit Other <br /> Property Line Private Dome Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL j <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I <br /> ❑ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 1p OTHER Other Information 3 <br /> 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> i' <br /> Type of Pump C`f W _ H P �_�i•` <br /> PUMP <br /> REPLACEMENT-0-State Work Done r <br /> PUMP REPAIR: State Work Done ® ♦r tea, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have <br /> 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, f <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 /> ! wit call for a Grout Inspecti n ri to r tin4andal inspection. r ;p Apt) <br /> Signed X le: I Date: l(Drawon Reverse Side) <br /> F R D PARTME USE ONLY <br /> PHASE I t <br /> Application Accepted By C <br /> O d <br /> Additional Comments: s Date -5 <br /> Phase II Grout Inspection Pha Q a! Inspection c� <br /> Inspection By. '� Date Inspection 8y Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN r 4❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 t ❑ July 1 &Received 8y July 31 <br /> BILLING ' REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ' AMOUNT <br /> FEE <br /> LESS 1� <br /> PRORATION + ' <br /> .� <br /> PLUS - <br /> --- {PENALTY <br /> OTHER <br /> OTHER <br /> �,4Received by .� Date:- -Receipt No 4 ..�"'� Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAI.HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.'P:O Bo■2009 STOCKTON,CA 95201 <br />