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applicationsWillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR_nFFICF USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan 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. 1862 and the rules and regulations of the San Joaq in Local Health District. r <br /> Exact Site Address % r►, ,. h/ i T/, t Lf�lr 1i,�t a*,Or, ./( AJ,- ; 7 .,f City/Town /I <br /> Rd <br /> Owner's Name / } Phone <br /> Address 0,? <br /> ( J L- k1 ,1,„r r, City 4 ci r <br /> Contractor's Name pinCe Dri ers Dri ing Corp License #3 Business Phone <br /> Contractor's Address _ �• ['ox 6 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONIM DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Feld Cesspool/Seepage Pit Other__ <br /> Property Line Private Domestic Well Public Domestic Well a4 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE 0 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 ❑ OfHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � c 1_17 <br /> Type of Pump 5 ,4 b,), / / H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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,reguiations of the San Joaquin Local Health District. <br /> z <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." I <br /> Contractor's hiring or sub-contracting signature certifies the following;"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call to a Gr nspectionyrior to grouting and a final inspection. r <br /> Signed X Tide: �Yc S s�C r7 Date: r.% <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted 8y ' <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMlTTEp AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> hi <br /> Received by 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.Boa 2999 STOCKTON,CA 95201 <br />