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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION /_1-_3T ^ <br /> (For Non-Transferable, Revocable,Suspendable) J PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 17? <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co my`Or�ina e No. 862 and the rules and regulations of the SanJoaquinLocal Health District. <br /> Exact Site Address .�,�0 r� � fh)y 'DrtZ4, City/Town`` �1�G-6LC.c.II <br /> Owner's Name Phone 7l� �Y —C? 300 <br /> Address _ Citlpqc��S� <br /> Contractor's Name License#j? 7/ Business Phone 835 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No s <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION iF_ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ILA- <br /> Property <br /> Sewage Disposal Field Cesspool/Seepage Pit Other v- <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ 11 yLD ATRIAL ❑ CABLE TOOL Dia. of Well Excavation- <br /> ®/DOMESTIC/PRIVATE ❑ DRILLED pia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 7%\ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sdrf a Seal Installed By-_ . <br /> PUMP INSTALLATION: Contractor _ Q <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 C <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:A 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 subject to workman's compensation laws of California." <br /> I will Grout Inn.20ion prigr 10 grouting and a final inspection. <br /> Signed Title: Date:R-� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ii� -oz/Application Accepted By - - - ( Date ! <br /> Additional Comments: <br /> Phase II Grout Inspection hij/ nal Inspection <br /> Inspection By Date Inspection By Date <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 /> B $ <br /> ABASE EXPLANATION BILLING REMITTANCE AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <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/SERVtCES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />