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I Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> r, <br /> ("Nor Non-Transferable, Revocable,Suspendable)"""") <br /> i1 - PUMP&WELL r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY N <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 Joaquin County Ordinance No. 1662 and the u es and regulations of the San Joaquin Local He lth District. <br /> 4 JCCExact Site Address 9 S� S City wn <br /> { Owner's Name P nee <br /> Address Ci <br /> Contractor's Name / License# ���1/ Business Phone /do <br /> Contractor's Address ;5l7/� �r�.���x�d Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes.._�� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ N. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines�U {� Pit Privy <br /> Sewage Disposal Field fDU r1_ 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 /> ❑ DOME=STIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> cc❑ DOMESTIC/PUI3LIC ❑ DRIVEN Gauge Of Casing <br /> �c+ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> a CATHODIC PROTECTION _ ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GhEOPHYSICAL Surface Seal Installed By: 6 k,;d Z1g <br /> PUMPINSTALLATION: Contractor <br /> 11 Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 1J <br /> PUMP REPAIR: ❑ State Work Done 6 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> e. Describe Material and Procedure <br /> 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County C' <br /> t 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 signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall emplo411 <br /> sons subject to workman's compensation laws of California." <br /> I w all for u spe or to grouting and a tinct inspection. /�� /� G� <br /> Signed X Title: _ Date:& Ar <br /> f� (Draw Plot Plan on Reverse(Aide) <br /> i FOR DEPAR7,< <br /> NT USE ONLY <br /> I PHASE I <br /> f Application Accepted By Date <br /> Additional Comments: <br /> Phase ll Grout InspectionIII Final Inspection <br /> r Inspection By Date Inspection B ha Date <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT L PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> ++ FEE _ <br /> LESS oil <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I1 <br /> B. <br /> Received by pate Receipt No. Permit No,S Issuance Date Mailed Delivered <br /> l APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />