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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 77 <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sgan Joaqu C[oImy Ordinance N 1862 and the rules and regulations of the Sa oagyin Local Health District. <br /> Exact Site Address��7 7 r City/Town -�-c, <br /> ,< Phone C� "�(9 1 <br /> Owner's Name I <br /> Address { L City <br /> Contractor's Name 0 License#/G 23 7 Business Phone 3 1 <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Witti SJLHD? Yes No <br /> TYPE'OF WORK (CH ECK):�NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ IvS <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tan . Sewer Lines Pit Privy <br /> Tank <br /> Sewage Disposal Field� Cesspool/Seepage Pit Other <br /> t. <br /> Property Line Private Domestic Well Public Domestic Well. <br /> INTENDED USE TYPE OF WELL ) <br /> I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation. <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I <br /> e f ! I <br /> ❑ DOMESTIC/PUBLIC ❑ Gauge of Casing. <br /> 9 9: <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Groutf y l <br /> ❑ DISPOSAL_ 11OTHER_ Other Informations <br /> J <br /> ❑ GEOPHYSICAL -% t At Surface Seal Installed By: I <br /> ,. <br /> PUMP INSTALLATION: Contractor I. P <br /> �� Y <br /> Type of Pum H.P. <br /> yp p : L I <br /> PUMP REPLACEMENT: <br /> ti 0�..,, �State Work Done <br /> ' <br /> PUMP REPAIR: 'bl State Work Done .l F Q �f ' <br /> DESTRUCTION OF WELL: { yWell Diameter Approximate Depth <br /> ' Describe Material dpid Procedure I <br /> I hereby certify that I have prepared thispa p II cation and that the work will be done in accordance with San Joaquin County <br /> ! ordiriances, state.laws, and rules and regulations of the San Joaquin Local Health District. _ <br /> Howner of licensed agent's signature certifies the following:"l certify that in the pertormanceof the work for which this permit <br /> ome <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." T <br /> I cal r a Grout pection prior to routing and a tinaL Ii on. {} <br /> Title: ' pate: <br /> Signed X — <br /> (Draw Plot Ian on Revers ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Datiu Elf Y <br /> � <br /> Application Accepted By b l <br /> Additional Comments: <br /> Phase 1 rot Inspection II Finale InspectionInspection By Date Inspection BA�a&e <br /> Date <br /> a , <br /> l <br /> Fee Is DUB: ❑ ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January.1 &Received By January 31 ❑ July 1 8,Received By July 31 <br /> ;EMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r <br /> DATE DATE REMITTED AMOUNT <br /> y FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .. <br /> OTHER 1 �t <br /> OTHER <br /> 3o a �- <br /> Received by Date Receipt No. ermit No. Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />