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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 Districtforapermit toconstruct and/o rinstallthework 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 A). City/Town <br /> p d3.c.d a« Ji 7 74e <br /> Owner's NamtA'�sAJ� Phone16o�L� <br /> Address 5 City S7WC +L'AJ <br /> Contractor's Name 1�14CXFiCk r License#333900 Business Phont;f�R«9)X-96 <br /> Contractor's Address +�U•r ®x � A (�> 1i/� 4.4�4-9a Emergency Phone' <br /> Is Certificate of Workman's Compensation Insurance File With SJLHD? Yes No 3 <br /> TYPE OF WORK (CHECK): -'NEW WELL OwDEEPEN 13RECONDITION❑ DESTRUCTIO,NC <br /> WELL CHLORINATION 11WELL ABANbtNMENT 11OTHER ElPUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank le 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 si <br /> 0. DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing gyp- & <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 5.G N�iJ /6C <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 19 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 0 <br /> PUMP REPLACEMENT: ❑ State Work Done d <br /> PUMP REPAIR: ` ❑ State Work Done --- — of <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth p <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 /> Homeowner or licensed agent's signature certifies the following:1 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this r� , <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> -1 will call f a Grout Inspection prior to grouting and a final inspection. <br /> Signed X — Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By ©� Dates1 <br /> Additional Comments: <br /> Phase2l Grout Inspection Phase III Final Inspection <br /> Inspection B �7W ate <br /> y Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY . ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r r� <br /> FEE <br /> LESS > <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER - <br /> 16 <br /> Received by bate I Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT=RETIJIRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTeON AVE.,P.D.Boa 2009 STOCKTON,CA 95201 <br />