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Applications Will Be Processed When Submitted ProperlyCompleted. Be sure Ioaign 1ne-ppolill—,.. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> = ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> pD -�Z <br /> zC <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> mad '/ c li ce-with San Joaqu}n County Ordinance No. 186n2 and the rules and regulat'ons of the S L Joaquin LocalP. Health District. <br /> mad <br /> F S }(V`E 1 �y 16 I�SEl�1�7� 1+UU�6STfF }{tu lc� ity/Town <br /> Exact e A dress_ - <br /> Owner's Name DCC.IDC-�N I- <br /> C. ►C/}c LoMPflN Phone <br /> Address •O. b City L <br /> 1 <br /> Contractor's Name - - <br /> �E L & License# �1 Business Phone_ _ <br /> Contractor's Address 3_8 "5 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No O <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT B— OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ -� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t pp <br /> Property Line Private Domestic Well Public Domestic Well Lill �n <br /> T- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE B DRILLED Dia. of Well CasingVill <br /> ' <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 /> EI �� �Lrl�7KHN�CaL su f ce Seal Installed By: <br /> (0 <br /> PUMP INSTALLATION: Contractor .[ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 11State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Cb <br /> Describe Material and Procedure N <br /> n <br /> r 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 thework 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 ofthe work forwhich this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X i7S Title: <br /> ~ (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 f Date .a1 ' <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection FlnspectioInspection ByDate Inspection B ase Ill •J-Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> (f. FEE <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> I OTHER <br /> k' <br /> OTHER <br /> aq- <br /> �.- <br /> t Received by <br /> Date - Receipt No. Permit No. I suanc Date Mailed Delivered <br /> ', APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />