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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign;T1ie Application. LFOR OFFICE USE: APPLICATION 1-`,,;� <br /> t <br /> „. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL!�� <br /> ENVIRONMENTAL HEALTH PERMITWCAL <br /> `' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY DISTRICT <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> madei in compliance with San Joaquin County Ordinance No.1862 and thpprulees and regulations of the San aquin Local Health District. <br /> Exact Site Address �� l��n Irl,- City/Town ! <br /> Owner's Na RL616ne , e I <br /> Address . , i Ci y' �. <br /> Cont actor's Name '' License# usiness Phone <br /> Contractor's Address Emergency�Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4 No <br /> TYPE OF WORK(CHECK): NEW WELL© DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATIONPUMP REP <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST:. Septic Tank Sewer Lines Pit Privy <br /> I` 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 /> ❑ DPMESTIC/PRIVATE ❑ DRILLED 4 Dia: of Well Casing <br /> WD'DOMESTIC/PUBLIC ❑ DRIVEN ' ' Gauge of Casing'• <br /> ❑ IRRIGATION ❑ GRAVEL PACKDepth Of Grout Seal <br /> ❑ CATHODIC PROTECTION 11 ROTARY ^-�-� Type 0.6 rout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> t ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor'~" I k <br /> L <br /> Ty�pe of Pump i HT. <br /> PUMP REPLACEMENT: IlEi ork Done <br /> PUMP REPAIR: S� tate Work Done f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure • r' <br /> 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> i 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 I wi r a Grout Inspecti rior t ' routin nd a final lnspection.- - ) <br /> Signed Title: ' Date: <br /> w (Draw Plot Plan on-Revers/ide)i <br /> ' t FOR DEPARTM7LISE ONLY <br /> i v <br /> i PHASE I � <br /> Application Accepted y _ Date <br /> � Additional Comments. T_ <br /> Phase II prout Inspection tws"I FinalVirispection <br /> I Inspection By Date Inspection By Date g--.---- <br /> 57i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH: ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> l <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $_ <br /> ' - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> !� FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i. <br /> OTHER <br /> (,5q (-8 cd;E-3 <br /> f . <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 'I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> I <br />