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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION /I <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -; A <br /> (COMPLETE IN TRIPLICATE) ���F-�f�1���� 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 compliantey1Nith San Joaquin County rdinance Nor 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address`2 / `I�r ST` S FA V City/Town M�� <br /> f. <br /> Owner's Name Q v ilw'Tt S Phone W <br /> Address V tr� XZ� �'S A dW4" eO ni. ra.L.. + City <br /> Contractor's Name -+C.1V1� C License#37 _ Business Pllone <br /> Contractor's Address 10 2.21f. ":Ck&*A r CO Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on FiSJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ ':'DEEPEN4e RECONDITION❑ DESTRUCTION❑- -" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 , 160 ItY'bAL'MOVJ4Q01IrC.�AI)�DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL tie <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> VIn <br /> GMESTIC/PUBLIC ❑ QRfGEN Gauge of Casing ornRIGATION 1GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <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 /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 arty 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 subjeot to workman's compensation laws of California." <br /> I w I �tInspe n prior to grouting and a final inspection. <br /> I •'f <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> P In <br /> Application Accepted!By -- T Date zA&, <br /> Additional Comments: <br /> Phas I rout Inspection a e III Final Inspection t <br /> Inspection By Date Inspection By - Date <br /> Feels Due: E.) ANNUALLY El UNIT El PER SITE ❑ EACH� ❑ January 1 &Received'By January 31 ❑ July 1 &Received By July 31 <br /> - � . REMIT - <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION ` <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> 3 'y <br /> Receive y Date 'Receipt No Permit No. Issuance Date. Mailed Delivered <br /> APPLI ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> J <br />