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plications Will Be Processed When Submitted Properly Completed.Be SureIo sign IneraPPuaa►r�rr. <br /> 5tATE) <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP &WELL <br /> ll ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <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 /> made in compliance with San Joaquin County Odinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> le <br /> Owner's Name + MQ1r �a !"l�tts�,_�04�.- Phone. <br /> Address 49'VP City *� <br /> Contractor's Na License#/F3 _) C Business Phone <br /> Contractors Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ylith SJLHD? Yes.mak^ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION IJWELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR O� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <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 /> IN DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r , <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Sear I Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: 11State Work Done <br /> PUMP REPAIR: IM <br /> State Work Done r �"" ' y <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 /> 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." \h <br /> Contractor's hiring or sub-conlrecting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I it call for a Gr t Inspeolic�prior to,grouting and a final inspection. <br /> Signed X / Title: 6-f Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By <br /> ��•� � Date Z 3 <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received i3y July 31 <br /> REMBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance ate Mailed Delivered <br /> N AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E>HAZELTO <br />