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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f ' <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL iG <br /> ENVIRONMENTAL HEALTH PERMIT i t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is U[ <br /> l made in compliance with San Joaquin Count Ordina a Mi. 1862 and the ru s nd regulations of the San JoaquiP Lo�l Health District. ` <br /> Exact Site Address ^ / City/Town <br /> Owner's Name `s C(' . ! � t --�/!- Phone , .35�-- ��zz <br /> I Address City— <br /> Contractor's Name Lam' uJ >E I Cense# Business Phone r`,2- 7:4--7 <br /> Contractor's Address -,f C Emergency Phone CC —�is 7 <br /> t Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes_ — No I <br /> t TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ► WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 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 <br /> Property Line Private Domestic Well Public Domestic Well l <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> l <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal J l <br /> ❑ CATHODIC PROTECTION ❑ ROTARY . Type of Grout S <br /> ❑ DISPOSAL ❑ OTHER Other Information l <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ y H.P. <br /> ' PUMP REPLACEMENT: State Work Done .1st/JI"Z <br /> t PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> l t Describe Material and"Procedure--- <br /> I hereby certify that 11 have prepared this application and that he work'will be done in accordance with San Joaquin County S <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I 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 /> C6ntractor'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 shall employ persons-subject to workman's compensation laws of California." <br /> I w c IIfwe Grout nspection prior to grouting;and.a final-i pection. 1 <br /> Signed X _ l� <br /> t i Title: Date: S� <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY ` l <br /> I PHASE i. <br /> r ApplicationllAccepted.By Date ? �z(,��� +, <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Inspection <br /> ` �s d <br /> Inspection By Date Inspection By W Date <br /> Y <br /> ' Fee Is Due: ❑ ANNUALLY ElPER UNIT ❑"P.,ER SfT1= `O EACH ❑ January 1 &Rec ved By January 31 ❑ July.1 &Received By July 31 �. <br /> ' - REMIT <br /> +, - BILLING REMITTANCE ;, $ <br /> a 'BASE-,.....,,,.,.._EXPLANATION AMOUNT DUES -CHECKED, <br /> DATE, DATE REMITTED AMOUNT <br /> 'I — + <br /> FEE <br /> LESS e <br /> PRORATION <br /> PLUS A L , <br /> PENALTY4.— <br /> OTHER <br /> OTHER <br /> c�y 70 <br /> -Received by Date Receipt No Permit No Issuance Date - Mailed - tvered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 11 <br /> "ii ,. <br />