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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication. <br /> FOR OFFICE USE: � �� 'APPLICATION <br /> T (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) II WATER QUALITY <br /> ' Application is hereby madetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed,Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 an the ules and regulations of the San Joaquin Loc' alth District. <br /> Exact Site Address C City/Town <br /> ,rte �i <br /> Owner's Name I,7- A I! P6 1 _r Phone <br /> Address „`� o� Jam— City <br /> Contractor's Name License# — Z Business Phone— <br /> 'C <br /> hone <br /> Contractor's Address .2 A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W' SJLHD? Yes 1K No <br /> r TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C PUMP REPAIR❑ <br /> REPLACEMENT❑ �i J .+ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ <br /> Sewage Disposal Field Cesspool/Seepage Pit OtOer <br /> 1 Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1 <br /> h <br /> ! DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ” ❑ DRIVEN Gauge of Casing <br /> © IRRIGATION. I ❑ GRAVEL PACK .;Depth of Grout Seal <br /> 6 ❑ CATHODIC PROTECTION I ❑ ROTARY -iType of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> ! PUMP INSTALLATION: Contractor <br /> Type of Pump 11 X Ae H.P. <br /> j PUMP REPLACEMENT: State Work Done �"''`� <br /> PUMP REPAIR: State Work bone <br /> i <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth <br /> I: Describe Material and Procedure <br /> I 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 /> 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 anyrperson in such manner as to become subject to workman's compensation laws of California." <br /> a. <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> per 't is issued, I shail- employ persons subject to workman's compensation laws of California." <br /> T . <br /> I w'I call for a Grout Insp to p r gr ting and a final inspection. <br /> Signed .. e7 _ fie: �?^z — Date: / <br /> i (Draw Plot Ian on Reverse Side) <br /> i <br /> r <br /> �I F EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By' Date l <br /> Additional Comments: 11 <br /> Plias 11 Grout Inspection Phase I i Inspection ��11 <br /> Inspection By Date Inspection By Date <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> Fee Is Due: El ANtvuALi Y11 El PER UNIT <br /> { liREWT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> II .DATE DATE REMITTED AMOUNT <br /> PEE <br /> LESS it <br /> PRORATION n <br /> PLUS Il <br /> PENALTY <br /> OTHER I� <br /> r <br /> OTHER <br /> I. <br /> 771 <br /> II <br /> Received by Date Receipt No ermit No. issuance Date Mailed Delivered <br /> A 95201 <br /> APPLICANT—RETURN ALL COPIES TO:- -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />