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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPL'ICATtON a <br /> cr (For Non-Transferable, Revocable,'Suspendable) / PUMP&WELL y <br /> 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 I, <br /> made in compliance with San Joaquin County Or finance No. 62 nd the rules.and regulations of the San JoaquiryLv��H District. <br /> City/Town <br /> Exact Site Address .+� " <br /> Phone <br /> Owner's Name n <br /> -QP` F <br /> Address , City` <br /> Contractor's Name �. � �° LLQ. License# Business Phone' <br /> Contractor's Address r " ° -tEmergency Phone F ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No u" <br /> TYPE OF WORK (CHECK): NEW WELL Mill DEEPEN-0 RECONDITION❑ DESTRUCTION <br /> ❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 0 ePUMP INSTALLATION®/'PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit � rOther <br /> Property Line :VOf Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED a <br /> ❑ DOMESTIC/PRIVATE Dia. of Well Casing <br /> ❑'DRIVENGauge of Casing G <br /> 13DOMESTIC/PUBLIC � 53 <br /> ❑ IRRIGATION �"C'RAVEL 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 t <br /> Type of Pump .�k H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br />' PUMP REPAIR: ❑ State Work Done <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 owneror licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance"of the work forwhich this <br /> permit is issued, 1 shall employ.persons subject to workman'i compensation laws of California." <br /> I will call for a Grout Inspedo r prior to grouting and a final-inspectioni- - <br /> Signed X Title: - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> :-^FOR DEPARTMENT USE ONLY <br /> PHASE tDate <br /> ' 8 <br /> t S� + <br /> Application Accepted By µ t Q�k1 1 <br /> Additional Comments: <br /> P e H Grou h�\ ha Ili F'aai Inspection <br /> Inspection By J- <br /> —�` �? Inspection By �- Date <br /> (' 1 <br /> Fee Is Due- ANNUALLY ❑ PER UNIT s}`�❑ PER SITE ❑ EACH ❑ January 1 &Received By J ary 31 ❑ July 1 8 ReceiveJuly 31Rd MI <br /> i C <br /> BASE EXPLANATION --•.+-131LLING.� .., ..-REMITTANCE„ $ ,AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F <br /> Oct <br /> EE <br /> 4 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> j5 �� <br /> Received by Date -Receipt No. Permit No. suan a Date Mailed Delivered A 95201 <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />