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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 (For Non-Transferable,Revocable,Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) y 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 3730 W12'SQSit-W City/Town Y <br /> Owner's Name Charlie' h' ers Phone: <br /> 466-0333_.} <br /> Address f0 "s uAL s= , <br /> City <br /> Contractor's Name MOOrmant: _ v' License#_2fy7A6 "Business Phone' } <br /> Contractor's Address " `% . ;sga' Z'• Emergency Phone : �k. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK): NEW WELL❑_ DEEPEN ❑ Y RECONDITION❑ .' DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONM_ENTUX- OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑. <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposai Field Cesspool/Seepage Pit Other <br /> Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ r <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ~ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout nl <br /> ❑ DISPOSAL ❑ OTHER Other Information 'r <br /> 11 GEOPHYSICAL Surface Seal Installed.By:. <br /> PUMP INSTALLATION: Contractor <br /> w <br /> Type of Pump � H.P. <br /> ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .�^ 1� -Appr ximate Depth <br /> Describe Material and Procedure' J f � <br /> 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 forwhich this permit <br /> is issued, I shalt 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 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 /> C4 <br /> Signed X' Title: <br /> - Date:. <br /> ` raw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE i <br /> Application Accepted By Date ✓ �( 2�®� <br /> Additional Comments: <br /> Be II out Inspection III l Inspection r <br /> Inspection By Date Inspection jBy - _pate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH -❑ January 1 &Received BY January 31 - ❑ July 1 &Received-By July 31 <br /> BILLING REMITTANCE .. $ -. 'REMIT <br /> BASE 41 EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE .REMITTED AMOUNT <br /> FEE J O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER t 3 <br /> OTHER <br /> Received by - - =Date- :+ -- -- -Receipt No _ Permit No:: - .. I uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />