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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR CPFICE USE: ,,)A APPLICATION ! <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ! <br /> ENVIRONMENTAL HEALTH PERMIT f <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin C unty dinance No.1862 and the rules and regulations of the San a�u Local Hepith district. <br /> Exact Site Address IJ City/Town <br /> Owner's Name 0 Q 0 Phone "' 0 <br /> Address City <br /> Contractor's Nam � .0 License# - rep Business Phone � <br /> Contractor's Address mergency Phone ^ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Ae--'— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f�/ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines `T Pit Privy <br /> Sewage Disposal Field �U �'7F1 Cesspool/Seepage Pit Al?!M+- 9 Other <br /> Property Line Private Domestic Well P.uW+c.r7loweatiq Well_ ti <br /> INTENDED USE TYPE OF WELL W41 Citf94r aAt ,.moo +--- <br /> ❑ IN�STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> UPSOMESTIC/PRIVATE ❑ DRILLED r Dia. of Well Casing <br /> -0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL�PACK �' Depth of Grout Sea <br /> ❑ CATHODIC PROTECTION i ZF{0 ARY 1 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal ailed By:fl��� /AeC <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11 ❑ State Work Donea <br /> DESTRUCTION OF WELL: Well,,Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this applicatiorr 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 /> + <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof 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 /> r Contractor's hiring or sub-contractin signature certifies the following:"I certify that in the performance of the work for which this <br /> ermit is issued, I shall employ a sons bject to workman's compensation laws of California." <br /> I 1 call fora Grout I sp r r to gr utin and a final inspection. <br /> 2 g <br /> Signed X Title:l o1(_W�#�/1_r Date: <br /> `.� 11�raw PIot=Rlan on Reverse Side) <br /> FOli DEPARTMENT USE ONLY r pp <br /> P I —!J 1 <br /> Application Accepted By <br /> t �- 0_3 Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection f U 'l Phase til Final Inspection <br /> Inspection By Date 1 cr �nInspection By Date <br /> 4 4 i`Yn e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> REMITTED <br /> i AMOUNT <br /> FEE J/f {�` $ -LJ <br /> LESS i`! Z�t4 f ti 1n— P� <br /> PRORATION <br /> PLUS 9� / r <br /> PENALTY �'/ � 5�,A P6 51C ^ <br /> OTHER <br /> OTHER <br /> i G <br /> Received ETy Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />