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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 7A-6 Iz <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIROj�MENTAL HEALTH PERMIT --- PAAt <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 <br /> made in compliance with San Joaquin County Ordi/napce 1862 an the ules an re ula'ons of the San Joagjn—Lo-cal H Ith District. <br /> Exact Site Address a 7 City/Town -=-��e "' �� <br /> Owner's Name 1, 11116027 N o Phone 9'..3 z 2 41 <br /> Address City <br /> 4�Contractor's Name � License Business Phoneme � <br /> Contractor's Address ��7 / 1.- --G� Emergency Phone 1�?� l .�G a <br /> Is Certificate of Workman's Compensation Iansura�n aon File With SJLHD? Yes �"'�` No <br /> TYPE OF WORK (CHECK): NEW WELL LDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank — Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property LinePrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND RIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing S <br /> ❑ DOMESTIC/PUBLIC ❑, DRGauge of Casing a <br /> ❑ IRRIGATION Gu" RAVEL PACK Depth of Grout'Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout q- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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'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 /> Contractors 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 /> will call or a ut Inspection prior to grouting an lipall inspection. <br /> Signed X •- Title: Date:. <br /> (Draw Plot Plan on Reverse Side) l <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By 1al © 2_ Date <br /> Additional Comments: <br /> h 11.•Gr ut Inspection P a ii ina Inspection <br /> Cry <br /> Inspection By - Date 4 _8 Inspection ByI AV <br /> e <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Az) <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY IS FS <br /> OTHER <br /> OTHER <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 />