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` Applications Will Be Processed When Submitted Properly Completed.Be sure I o sgn t ne \ <br /> F R OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) ,PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> • WATER QUALITY '" <br /> NEP(COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This app ication is <br /> made in compliance with SaJoaquin Count ;dinance No.1862 and the rules d regulations of the San Joaquin Local District. <br /> Exact Site Adtlre .e -= City/Town —44 a� <br /> c Phone <br /> Owner's Name T <br /> City <br /> Addressusiness Phone <br /> Contractor's Name f! License# 4 r <br /> Contractor's Address C Emergency Phone <br /> ZZ <br /> Is Certificate of Workman's Compensation Insure ce on File With SJLHD? Yes 1.. No j <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN C3 RECONDITION 13DESTRUCTION' ❑ <br /> WELL CHLORINATION ❑, WELL ABANDONMENT ElOTHER 13PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> N. <br /> REPLACEMENTMI`-- Pit PrivI � <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal Fieltl Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation - <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> '❑ DOMESTIC/PUBLIC - ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION v ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC'PROSECTION ?�".❑ ROTARY Type of Grout <br /> 13DISPOSAL ❑ OTHER "� Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION. .y Contractor �/��tY <br /> Type of Pump �1 ..ia7 f'r:fL -O H.P. a `A2EsiPl�� <br /> PUMP REPLACEMENT: " ffi'State Work Done t <br /> • PUMP REPAiRi;: °- ti''- ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameiet`f <br /> a, Describe Material and Procedure <br /> I hereby certify that I have prepared this appUcation.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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I III call for a Grout In tion prior to grouting and a final insp,yp,¢5If n. / <br /> / <br /> 1 <br /> Title, s+w.J <br /> Signed X Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPAR7MENT USE ONLY J <br /> PHASE 1 <br /> Application Accepted By <br /> Additional Comments: ce 1 nal Intilt.. <br /> Phase It Grout Inspection Date <br /> Inspection By Date Inspection B <br /> Fee 18 DUG: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1 eived 8Y Jenlrory 31 ❑ July 1 a ReceivedREMIT MY 31 <br /> BASE E%PI.ANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> rte- c <br /> FEE <br /> OU , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Perml Na, Iseu nce Oate Mailed belly <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERSIIT/SERVICES <br /> )set E.HAZELTON AYE.,P.O.Box 20ae STOCKTON,CA <br />