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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign tineAppHcanon. <br /> FOR OFFICE USE: APPLICATION ! <br /> C <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 District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> ! Exact Site Address 7a G-7 W L ZL+ld / A City/Town <br /> Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name a License# /�3-�1Y1� Business Phone9. <br /> Contractor's Addressaw AFes Emergency Phone <br /> r `p <br /> Is Certificate of Workman's Compensation Insurance on Pile With JLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 01 PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 4 '- <br /> tf• Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line . Private Domestic Well^ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 14 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information F <br /> ❑ GEOPHYSICAL Surface Seal Installed' <br /> PUMP INSTALLATION: Contractor - '�•�'/ <br /> Type of Pump �m r. H.P. 01C3 10"P t 4 <br /> p <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP W60*IR: ® State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter pP p ii <br /> Describe Material and Procedure NI§ <br /> rI�I <br /> I hereby certify~that'I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. rk <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> 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 all for a Grout Inspecti t o din nd a final inspection. <br /> I Signed e: _ Date: <br /> {Draw Plot an on Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> I � (� � _ <br /> Application Accepted B ������""-"' W\!+-OLr Date <br /> Additional Comments: <br /> PI se II Grout Inspection RhaV III Final 1f pection <br /> Inspection By—AyDate Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> is <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED "! <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> f 'd <br /> PLUS <br /> PENALTY <br /> OTHER <br /> R! <br /> - f! <br /> OTHER ``•+ - <br /> Received by <br /> Date GReceipt No. Permit No. I uance rate Mailed Delivered _ 4 <br /> i� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />