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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> FOR OFFICE USE: APPLICATION <br /> E. <br /> (For Non-Transferab%, Revocable, Suspendable) PUMP&WELL <br /> T' 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 Local Health District. <br /> Exact Site Address �7_z86 40� d/7 City/Town <br /> Owner's Name lei%y' NS T!V7iN f�e Phone-. <br /> Address 2 N S ✓ 6 City .0 (Z 740 <br /> Contractor's Name License# V1 Business Phone 4110--SZ 3 S-6 <br /> Contractor's Address Emergency Phone `S' <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❑ .t ! ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other [i <br /> Property Line . 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 '❑—DRIVEN' Gauge of Casing T <br /> ❑ IRRIGATION ❑ 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 r <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: X Well Diameter �.a <br /> Approximate Depth' ' <br /> Describe Material and Procedure <br /> i <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County P <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 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 ;�nsPection <br /> em toy persons subject to workman's compensation laws of California." <br /> I wilt II f a Gro or to grouting and a final inspection. <br /> Signed X Title. 5'7r//�7��2— Y Date: I <br /> (Draw Plof Pian on Reverse Side) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By_"n Date <br /> Additional Comments: <br /> Phase 11 Gra1Rate- <br /> ction 1 Phase III Final Inspection <br /> Inspection By —Z 1 Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑.PER UNIT ❑ PER SITE ❑ EACH ❑-Januar' I &Received By January 31 ❑ July 1 &Received By July 31 <br /> r _ <br /> REMIT <br /> BASE EXPLANATION REMITTANCE � <br /> .BILLING REMITAMOUNT DUE CHECKED <br /> � <br /> 3, DATE DATE REMITTED, AMOUNT_ <br /> hFEE <br /> LESS 1 4 4 <br /> PRORATION --' <br /> PLUS <br /> PENALTY t ' <br /> OTHER - <br /> OTHER <br /> qoc <br /> Received by Date Receipt No. Permit No-- - - Issuance Date Mailed Delivered Fe <br />` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA ; <br /> 5 <br />