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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE ? <br /> ) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an a LIES and regulations of the San Joa Lin L al Health District. <br /> Exact Site Address 81-9: City/Town <br /> Owner's Name L J04y 40- <br /> Address a Idol Phone (�`Q^3 Qp8 S <br /> Contractor's Name City - <br /> Contractors Address License tf Business Phone <br /> Is Certificate of Workman's Com Emergency Phone <br /> pensation Insurance on File With SJLHD? Yes No ! <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E3. OTHER ❑ <br /> . DESTRUCTION❑ <br /> REPLACEMENT❑ PUMP INSTALLATION ❑ PUMP REPAIR ..y <br /> "DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy _ <br /> Sewage Disposal Field Cesspool/Seepage Pity. <br /> Property Line Private Domestic WellOther <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIALS ❑ CABLE TOOL <br /> ❑ DOMESTIC/PRIVATE Dia. Of Well Excavation ' <br /> ❑ DRILLED Dia.of Well Casing :+ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 13DISPOSAL e of Grout - <br /> ❑ GEOPHYSICAL ❑ Other <br /> OTHER Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P.State Work <br /> PUMP REPLACEMENT: ❑ <br /> Dane <br /> PUMP REPAIR: M'State Work Done lid If w if <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> proximate 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:"l certify that in the performance sof the work for which this permit <br /> is issued shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contrac Ys Kirin or sub-contracting signature certifies the following: <br /> permit issue shall employ 9:"I certify that f the performance of the work for which this <br /> p y persons subject to wor 's compensation laws of California." <br /> I will If for rout Inspection p;:7=11dal ins al <br /> peetlon. <br /> Signed X <br /> itle. �7 r�J//1(aY Date: <br /> (Draw Plot Plan on Reverse Side) ! <br /> 1 <br /> F DEP RTMENT BE ONLY <br /> P EI i <br /> Applicadion Accepted By <br /> Additional Comments: Date y } <br /> Phew 11 Grout Inspection r <br /> haw 111 Final Inspecli <br /> Inspection By. Date Inspection B ,�,� �� ��- <br /> at 4 ; <br /> i <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 9y Jenuery 31 <br /> 13 July 1 a Received 9y July 31 <br /> BASE EXPLANATION BILLING REMITTANCE y REMIT , <br /> DATE GATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER Y <br /> OTHER <br /> _ Re29i E�by Be \ Reteipl Na Permit No. luuanee re Mailed Delivered - <br /> APPLICIOR—RETORN'ALL COPIES To: ENVIRONMENTAL HEALTN'PERMIT/SERVICES 101 E.HAIELTOM AVE.,P.O.Boa 20e9 STOCKTON,CA 9SM1 ]i <br />