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Applications Will Be Processed When Submitted Properlycompiezeo. tie sure IvOrgTI IFIV•+rr••�a• <br /> FOR OFFICE USE: !a "� M~ APPLICATION l <br /> a (For Non-Transferable,-:Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) it <br /> Application is hereby made to the San'JoaquinLocal Health Districtforapermit toconstruct and/or install the work herein described.Thisapplicationis f <br /> made in compliance with San Joaquin County Or inane No. 1862 and the r le and regulations of the San Joaquin Local Health District. <br /> Exact Site Address b1J£ City/Town <br /> -71 <br /> Phone <br /> Owner's Name <br /> Address V City-L, 01-7 3 7 <br /> Contractor's Name mcs <br /> License# � a Business PhoneLContractor's AddrestS4Contractor's Address � � s� Emergency Phone <br /> Is Certificate of Workman's Compensation Ins ranee on File With SJLHD? Yes — NO <br /> TYPE OF WORK (CHECK): NEW WELLR DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ !T .-- <br /> DISTANCE TO NEAREST: Septic t Tank Mde Sewer Lines <br /> � Fl _ Pit Privy <br /> -1- I Cessp of/Seepage Pit ��� Other <br /> Sewage Disposal F4eld I <br /> ss <br /> Property Line_ Private Domestic Well 1 f Public Domestic Well <br /> INTENDED USE TYPE OF WELL. <br /> ❑ INDUSTRIAL I CABLE TOOL Dia:--ot-WeN,Excavation-- <br /> 11-DOMESTIC/PRIVATE i' a ._❑-DRILLED-'�"�' ' Dia:of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION �� 13 GRAVEL PACK Depth of Grout Seal ._� <br /> ElCATHODIC PROTECTION 11ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL ;i Surface Seal Installed By: 6 <br /> PUMP INSTALLATION: I' Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ; ❑ State Work Done <br /> DESTRUCTION OF WELL: i Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." j <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 employ persons subject to workman's compensation laws of California." <br /> I will call for a ro t in p cti n prior to grouting and a final inspection. ✓�a� �/ <br /> i <br /> Title: _ Date: <br /> Signed X <br /> II (Draw Plot Plan on Reverse Side) <br /> --FOR DEPARTMENT USE ONLY _ 7 <br /> PHASE I Date <br /> Application Accepted By I <br /> Additional Comments: y / <br /> Phase III Final Inspection <br /> Phase II Grout Inspection <br /> !! Date inspection By <br /> III ��Date � G <br /> Inspection By <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> BASE' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE F !I <br /> LESS <br /> PRORATION Imo. <br /> PLUS I� <br /> PENALTY <br /> OTHER <br /> .. OTHER <br /> Received by Date <br /> Receipt No. Permit No. Issuanc Dat Mailed Delivered <br /> E APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />