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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) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Joaquin County Ordinance No, 18 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �2Y�J�� e '1Gc, - U- City/Town <br /> Owner's Name Phone S7 <br /> Address City <br /> Contractor's Name r License#—.3'2J'2ZBusiness Phone <br /> Contractor's Address rj��z 4 Emergency Phone <br /> Is Certificate of Workman's CompensatiA 1 urance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IBJ DEEPEN ❑ RECONDITION❑ DESTRUCTIONZ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ _ <br /> DISTANCE TO NEAREST: Septic Tank 7751 Sewer Lines 90 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Ir : <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 12- <br /> DOMESTIC/PRIVATE ® DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 02 0 <br /> ❑ IRRIGATION m GRAVEL PACK Depth of Grout Seal ;:5-0 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> j <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure � J <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <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." f <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 will for a Grout Inspe tion prior to grouting and a final inspection. <br /> Signed X y Title: - Date: ��/ /Wlo <br /> 05TDraw Pian on Reverse Side) <br /> i F R DE ARTnu <br /> SE ONLY <br /> PHASE I �Z <br /> Application Accepted By—', '°'`�`MEDate eu <br /> Additional Comments: - Q � <br /> Ph s II Gr ut I spec ' n P ase III Final Inspection <br /> Inspection By Inspection By Date '�." h <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED <br /> (�(� AMOUNT ,ti <br /> FEE <br /> LESS <br /> PRORATION <br /> f. <br /> PLUS I <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> W. Received by Date �q Receipt No Permit NoIssuance Date Mailed Deliver@d ' <br /> APPLICANT—RETURN ALL COPIES TO: m ENVIRONMENTAL HEALTH PERMIT/SERVICES 0 .HAZELTON AVE.,P.O.Sim 2009 STOCKTON,CA 992 <br />