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,y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `"''FOR OFFICE. USE: APPLICATION � a _Oh ^�L. <br /> (For Non-Transferable, Revocable,Suspendable) <br /> . 110 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 Ordinance No. 1862 and the rules and regulations of the San Joaquin Local ealth District. b <br /> Exact Site Address _J`�663; Al VIA (�Dl City/Town <br /> Owners Name <br /> Phone + <br /> Address City 4/V <br /> Contractor's Name License# Business Phone G oa <br /> Contractor's Address —�74 4 ^6 iryp 45 r' Emergency Phone "' I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q s <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLAC1rMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ I Sewer Lines /04> Pit Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit _ Other <br /> Property Line Private Domestic Well 'tlTl Public Domestic Well W <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL E3 CABLE TOOL Dia. of Well Excavation <br /> UJDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing j <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �- <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal �I: j ' <br /> 11 CATHODIC PROTECTION '� ROTARY Type of Grout �+ <br /> ❑ DISPOSAL ❑ OTHER Other Information a d <br /> GEOPHYSICAL Surface Seal Installed By: L1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done l <br /> PUMP REPAIR: ❑ State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> D scribe Material and r c Jure <br /> Sbr � <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 /> m subject to workman's compensation laws of California." <br /> is issued, I shall not employ any person in such manner as to become P <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout inspection pri r to grouting and a final inspection. <br /> i <br /> Signed X Title: _ Date: - � — <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE I <br /> Application Accepted By Date . <br /> Additional Comments: <br /> gas II aLit Inspection P as-p III Fii al Inspection <br /> � Ins ection B <br /> Inspection By Date P Y ate <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> E DATE DATE <br /> DATE REMITTED AMOUNT <br /> �FEE /7. 140V + <br /> SS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> Received by Date Receipt No. Permit No Istuance Date Mailed Delivered <br /> {. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />