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Applications Will Be Processed When Submitted Properly C' repleted. Be Sure To Sign The Application. <br /> + FOR OFFICE USE: /// APPLICATION <br /> "PT _ _ (For Non-Transferable,Revocable, Suspendable) �a <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,COMPLETE IN TRIPLICATE) 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 Ordi pce N . 1862 and the rules and regulations of the San Joaq In LOCV H alth Dist- t-! <br /> Exact Site Address b D4-0 /� re�,.I' City/Town <br /> c' <br /> Ow,nei s Name d I Pot __._ � Phone - l�c'a v <br /> Address /n�' ��.�—� t ��S City r <br /> fContractor's Name License# r9_�'9z-S"Business PhoneZ ?�7 <br /> Contractor's Address Emergency Phone' <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes�_ No <br /> r TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ECONDITION❑ DE57RUCTION❑ <br /> p IX <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP'REPAIR❑ , <br /> REPLACEMENT❑ G <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field - •Cesspool/Seepage Pit Other \rT^ <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL " <br /> ❑ INDUSTRIAL t ❑ CABLE TOOL Dia. of Well Excavation--- <br /> 11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — --. <br /> ❑,IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ,.CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICALj. ,. �/ Surface Seal Ins Iled By: <br /> PUMP INSTALLATION; Contractor �m41 1 <br /> •� � Type of Pump - <br /> S H.P. <br /> f PUMP REPLACEMENT: ❑ State Work Dof1e <br /> % <br /> PUMP ir1EP1111110t' 9-State Work Done" -T�° 'L� <br /> DESTRUCTION OF WELL: Well Diameter ' -` _ Approximate Depth. <br /> Describe Material and Procedure <br /> r <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 /> r <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 /> It is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I' Contractor's hiring or sub-contracting signature certifies the fallowing:"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 ill call for a Grout Inspects n p' to routi and ''neral inspection. <br /> Title: Date: 1 <br /> Signed X ,mss <br /> 7t J` (Draw Plot an on Reverse Side) <br /> F FOR DEPARTMENT USE ONLY I (� <br /> PHASE I ( �11 ' Dates.— { V� <br /> I Application Accepted'By <br /> Additional Comments: - <br /> Phase II Grout Inspection se Ili Final Inspection <br /> �e ��1�•,-, <br /> Inspection By <br /> 1 ____ Date Inspection By <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Receivec By January 31 ❑ July t &Recery dBy July 31 <br /> REMBASE. I EXPLANATION BILLING REMITTANCE £ AMOUNT DLIE CHECKED <br /> F DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> �. LESS <br /> PRORATION i <br /> PLUS <br /> ' PENALTY <br /> OTHER <br /> OTHER -- ----- - <br /> I' <br /> Received by Date Receipt No. Permit No. Issuan a Da Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITl9CA 95201 <br /> ERVICE4 .1601 E.Hp2ELTON AVE.,P.O.Box 2009 STOCKTON, <br /> i ' <br />