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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Tie Application. Ix,4 <br /> FOR OFFICE USE: )) APPLICATION <br /> I / (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 157V-2-0 5_. kr6,cr_aw "TER QUALITY j ^p/ <br /> Application is hereby made to the San Joaquin Local Health Distri tf a 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 AddressI!r/ o JO; City/Town <br /> e <br /> Owner's Name — Phone <br /> Address --S City �. L <br /> Contractor's Name �a0,z/-/ ,A-= License# L >,t Business Phone _Ira <br /> Contractor's Address Emergency Phone Z <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR)K r� <br /> REPLACEMENT❑ U l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C!)' <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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> FK IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ~ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ - <br /> ❑ DISPOSAL ❑ OTHER Other Information N <br /> ❑ GEOPHYSICALI Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ro d <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> r <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 /> Homeowner 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 /> 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 Inspect' n rior routin tad a linal inspection. s <br /> Signed a Title: . IC.! _. .. . Date: +� <br /> ' (Draw PI'W Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> T Phase II Grout Inspection case III Fina[ IrItipection <br /> Inspection By. Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> AMOUNT .I <br /> FEE Q� <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Is uance Qrale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />