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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICjr USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 6h.J 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 J6aquin Co my Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address f Cr / City/Town ,14 i <br /> I' Owner's Name 1Phone <br /> Address '. ) City 6 <br /> Contractor's Name / License Business Phone�� _ <br /> i` Contractor's Address U -vP Emergency Phone /./41 f Q� <br /> i <br />.,. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK)-. NEW WELL, DEEPEN © RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONO PUMP REPAIR {1`, <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /. , e? Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE J TYPE OF WELL ./ <br /> i ❑,4NDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> 'j-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑-IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �i <br /> ❑CATHODIC PROTECTION ❑ ROTARY Type of Grout _� {r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: L4i� ,Syti <br /> PUMP INSTALLATION: Contractor )I&n <br /> Type of Pump S i_, !)', � � H.P._� d <br /> _ In <br /> PUMP REPLACEMENT: 13 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 /> Home owner 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 /> 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 call for a Grout ins cctio prior togr uting and a final inspection. / l <br /> Signed X :yi� v Title: �__ �- f Date: 1TLI <br />' - (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> haseal Lit Inspection 4 ha If! Final Inspection <br /> I Inspection By Date I~ Inspection By Date <br /> i Fee Is Due: 13 ANNUALLY El PER UNYT -. El PER SITE ❑ EACH EJJanuary 1 &Received 6y January 31 ❑ July 1 &-Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE .I* CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE. `f7 <br /> LESS a_ <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> s it <br /> OTHER <br /> 1 <br /> OTHER <br /> Received y i Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />