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Applications Will Be Processed When Submitted ProperlyCompleted Be SureTosign meAppncanon. <br /> FOR OFFICE USE: h APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication 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 ith San Joaq County Ordinance No. 1862 and the rules and regulations of the San.-Y Loc I Health District. <br /> Exact Site Address t 3 Ig r L� City/Town <br /> 17 7 <br /> Owner's Na e l Phone <br /> Address 3 3 City <br /> Contractor's Name �l <br /> License#� - Business Phone "- 0 <br /> Contractor's Address Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No , <br /> TYPE OF WORK (CHECK): NEW WELL V DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Od <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank <br /> _f r`f` - Srer Lines d 4-- Pit Privy <br /> Sewage Disposal Field Cesspool/9eepage Pit Other--� <br /> Property Line Private Domestic Well CU ll -rte <br /> INTENDED USE TYPE OF WELL u <br /> ❑ INDUSTRIAL u ❑ CABLE TOOL Dia.of Well Excavatio <br /> 11 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC o ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION o 11 GRAVEL PACK � Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I! LY1 ROTARY Type of Grout AIe- � v" <br /> ❑ DISPOSAL I' ❑ OTHER Other Information TS' <br /> ❑ GEOPHYSICAL II Surface Seal Installed By: <br /> I PUMP INSTALLATION: I' Contractor- <br /> 1! Type of Pump H.P. <br /> PUMP REPLACEMENT: u ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> r 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 /> Contractor's hiring or�sub-contracting si nature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall emp so ss 'ect to workman's compensation laws of California." <br /> ill call for a Grout Ins a on rio grow' and a final inspec on. / c� <br /> Signed f- yTille: Date: I it'-' I d " a o <br /> ll r w Plot Plan on Reverse Side) <br /> u <br /> I <br /> II FOR DEPARTMENT USE ONLY <br /> Ih _, <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph 11 Grout Inspection Phase Ill Final Inspection <br /> Ins pectipn By .' l �� �'g Inspection By VIA Date <br /> 'J orL oil' <br /> Fee IS DUe: ❑ ANNUALLY:: ❑ R 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 /> F DATE DATE REMITTED AMOUNT <br /> 1 FEE Q <br /> LESS d <br /> PRORATION � <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> ' OTHER <br /> } 0 5 D D 47 <br /> Received by Date I Receipt No. Permit No Issuance Date Mailed Delivered <br /> ' <br /> STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20119 <br />