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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION J(dj <br /> or Non-Transferable,Revocable,Suspendati PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 1 T �y <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY h—�> <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Jo quin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Citylfown -/ --Q— r <br /> Owner's Name si�Vll' ""-=� � �'� Ph6ne �'G'' <br /> Address ��y F - City' <br /> Contractors Name License A-R? r _/ Business Phone <br /> Contractors Address O 1��,/(o_ /5'.e'�. Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDI Yes J No - <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN 13RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL. ABANDONMENT 11 OTHER 11 PUMP INSTALLATION D MP REPAIR❑ <br /> REPLACEMENT❑ ` w - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy "r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well . Public Domestic Well ,t <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND RIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> W,115OMESTIC/PRIVATE E] 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 /> 0 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑ $Bate Work Doing <br /> PUMP REPAIR: ❑ State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> 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.". <br /> Contractors hiring or subcontracting 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 ca 1 r•a Grout Ins ction prior to grouting and a final Inspection. <br /> Signed X G— t --"— Title: Date: <br /> ,(Draw Plot Plan on Reverse:Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: - <br /> Phase II Grout Inspection as net Inspection <br /> Inspection By Date . Inspection By Date <br /> Fee-is Due: 11ANNUALLY .❑ PER UNIT 0 PER SITE Q EACH ❑ January 1 &Received By January 31 �❑ July t 8 Received By July 31 <br /> . S REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ' DATE DATE�. REMITTED AMOUNT <br /> FEE 7cf <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t OTHER <br /> OTHER <br /> Received by Dale Receipt No. Pprmd No. fluence Date Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95301 <br />