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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, j <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 San Joaq in Qa4 ty Ordii;dnce No and the rules and regulations.of the San Joaquin Local Health District. <br /> Exact Site Address City/Town LC3& <br /> Owner's Name Q Phone Ct 31' 2-9 f5! <br /> Address City' <br /> Contractor's Name License# Sr_7`7048 Business Phone <br /> Contractor's Address �" Emergency Phone • - ) , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NO <br /> TYPE OF WORK (CHECK):' NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION <br /> El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ v L <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well: <br /> INTENDED USE. F TYPE.OF WELL w <br /> ❑ NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation .c" <br /> 9 <br />! PDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ` <br /> ZY <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout f � <br />' ❑ DISPOSAL ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL Sure Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t a - H.P. <br /> PUMP.REPLACEMENT: State Work Done_Ll <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter 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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:1 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." <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.VI r a Grout Inspec' prior groull g and a final inspection. <br /> t Signed X Title: ( ��[Lft_�� _._-...___ Date: <br /> c <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> go <br /> Apply �J <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection APha* III Anal 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 /> REMIT <br /> ,,: BILLING REMITTANCE $ <br /> BASE EXPLANATION 'AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ii LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -- - <br /> to 7 _ 30 2/ <br /> i Received by Date _ Receipt No. Permit No. I ssuancli Date Mailed- Defivered .. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />