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.f 4;11icAtten�s�WBePr(;cessedbi Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: s� �typ8 �� � APPLICATION <br /> e) or Non-Translerable, Revocable, Suspendable) PUMP&WELL <br /> � NRONMENTAL"HEALTH PERMIT <br /> �yJor-QUIN WATER QUALITY <br /> (COMPLETE IN TRIPLICATE �� -� I)IST ►� '� Q <br /> Application is hereby made tot anJoaquinLocalHealthDistrictforapermittoconstructand/or.installtheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ord Na. 1862 and the rules and re til ions of the SanlJo quin Local Health District. <br /> Exact Site Address S L ^A/1-� � City/Town �JQ� Xl�•L1nJ <br /> Owner's Name F` `r 6 ® A-/ <br /> Phone S r.l�D <br /> Address City ,��6 y2o 7 <br /> Contractor's Name License If��/o Business Ph ) <br /> Contractor's Address / lone <br /> �" 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 /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER Cl PUMP INSTALLATION PUMP REPAIR❑ <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 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1! DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13GEOPHYSICAL C eAI-Instal d BY:PUMP INSTALLATION: Contractor ,Surface <br /> "� <br /> Type of Pump SL H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ,- <br /> Describe Material and Procedure <br /> d <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 /> Homeowner 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 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 wi li for a Grout I ectlo rior to grouting and a final inspe <br /> Signed X Title: Date: <br /> {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE 1 O <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase IL Grout Inspection �hl Final Inspection <br /> Inspection By Date Inspection By. — U Date 0 _. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE" ❑ EACH ❑ January 1 &Received By January 31 July W Frec6 ed By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REVTTANCE $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �2-3 <br /> Received by I Date Receipt No, Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br />