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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: \ , <br /> FOR OFFICE USE: J 14W APPLICATION `f <br /> /® (For Non-Transferabie, Revocable, Suspendable) <br /> - 'PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT _ <br /> (COMPLETE IN TRIPLICATE) 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 Ordin4npe No.-186Zand the r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /higDr /�� If�el� • �Oi� City/Town <br /> Owner's Name Phone <br /> Address S' ! y - S & City <br /> Contractor's Name License# Ife-72-d "nsiness Phone 3- - :2 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJR D? Yes . No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN C1RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION, ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRIN <br /> REPLACEMENT❑ .j <br /> DISTANCE TO NEAREST: -Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _ Cesspool/Seepage Pit Other 1 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE _ TYPE OF WELL - <br /> ❑ INDUSTRIAL b ❑ CABLE TOOL.'' ^' Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED F _ 'Dia. of Well Casing - t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN �Gauge`-of Casing <br /> IRRIGATION ❑ GRAVEL PACK,— �"� -� Depth of'CEout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ` a <br /> Type of Pump H.P. �v <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF,WELL: Well Diameter _Approximate Depth <br /> Describe..Mate riai 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 performanceof thework for which this permit L.r <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 forwhich this <br /> permit i issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I all for a Grout Inspection r' r o roing and ai inspec,'on. ,.< <br /> Signed X +a itle: Date: <br /> (Draw Plot, Ian on Reverse Side)(Z <br /> M <br /> FOR PARTME USE ONLY i <br /> PHASE l16, <br /> Application Accepted By Date <br /> ti <br /> Additional Comments: t <br /> Phase II Grout Inspection I final Inspeclion <br /> Inspection By Date Inspection By G7� DaterlZ r� <br /> d <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT'. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January,31 ❑ July 1 &Received I <br /> BILLING REMITTANCE $ 1 RE <br /> BASE EXPLANATION AMOUNT DUE GHEC D - <br /> DATE DATE REMITTED .- ' : AMOUNT <br /> FEE — f <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY '- <br /> OTHER <br /> OTHER ". <br /> fi <br /> -Received by _. Date Receipt No. Permit No. - - Issuance Date, Mailed Delivered , <br /> APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,•P.O.Box 2009 STOCKTON,CA 95201 <br />