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► Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OF.FiCE USE: APPLICATION <br /> R (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ~ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetothe San Joaquin Local Health Districtforapermittoconstruct and/Or install theworkherendescribed.Thisappil`c tion.is <br /> made in compliance with San Joaq in County Ordinance o. 1862 d the rule nd regulations. the Say(Jo ocal Health.District. <br /> Exact Site Address <br /> 4 <br /> Owner's Name 'f ` `I .� Phone <br /> Address P r y yts•.Y.:. City } h .n <br /> Contractor's Name �` icense#2 �iz . Business Phone''^I�{y/- �16 <br /> t" ' Emer enc` Phoney- 1. ''h _.r.. <br /> Contractor's Address � � 9� Y <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes" / No i1 <br /> TYPE OF WORK (CHECK): - NEW WELL -DEEPEN ❑ _- RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank60 f Sewer Lines -- Pit Privy <br /> Sewage Disposal Field_/0 -E Cesspool/Seepage Pit Other �. <br /> F Property Line z Q {f Private Domestic Well �! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑. INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r <br /> $,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' 1 , <br /> ❑ DOMESTIC/PUBLIC Ii❑f DRIVEN Gauge of Casing l 6U 1� <br /> ` ❑ IRRIGATION J GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION 'Z-ROTARY Type of Grout r <br /> 0 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �12 r ll 01 vl <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 /> Homeowner or licensed agent'srsignature 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 forwhich this <br /> permit is issued, I shall•employ persons bject to workman's compensation laws of California." <br /> I wilLaeltVir a Grou s ion'p or grouting and a final inspection. <br /> LZ <br /> Signed X Title- Date: <br /> ( (Draw Plot Plan on Revers Side) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I ems' 60 r Date <br /> �, -JU-51 <br /> Application Accepted 8y- - {./ <br /> Additional Comment } <br /> P ell ou pe n/ ,P,h a III Final Inspection <br /> Inspection Date�� - �-•-- -Inspection By - Date <br /> r <br /> Fee Is'Due: - ANNUALLY ❑,PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑-July 1 &Received By July 31 <br /> REMIT <br /> SASE' EXPLANATION BILLING 4 REMITTANCE $ -AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 'LESS <br /> PRORATION <br /> PLUS y; <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Received by Date 'Receipt No. Permit No. Issuarick Date k IMRiled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />