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Applications Will Be Processed WhenSubmitted Propeny vompletea. owoure IV ONVI. •••�••rr - <br /> FOR OFFICE USE: APPLICATION <br /> f (For Non-Transferable, Revocable,Suspendable) PUMP&WEL:L. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or install the work 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 <br /> District. <br /> Health <br /> Exact Site Address 9�� - � orf r� kh City/Town <br /> Q,5 Phone 2 :3 <br /> Owner's Name _ -AIT <br /> Address — ! �lPd� D City <br /> j Contractor's Name _ <br /> License# �66 Business Phone <br /> Contractor's Address v2�.5 r / / Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—.t No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ElRECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONen PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Dispdsal Field Cesspool/Seepage Pit Other <br /> Property Lines Private Domestic Well-__ ­ Public-Domestic Well <br />{ INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 DRILLED Dia. of Well Casing I <br /> DOMESTIC/PRIVATE IN <br /> l ❑ 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 Information17 ­IV <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C <br /> PUMP INSTALLATION: Contractor _R ,4 H.P. <br /> Type of Pump N T <br /> r PUMP REPLACEMENT: ❑ State Work Done •f► <br /> PUMP REPAIR: ❑.State Work Done <br /> t Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 U <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I 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 /> Contractor's hiring or sub-contracting 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 /> r <br /> Iwill all or a out Ipecti prior grouting and a final inspectio III, `r <br /> Signed X <br /> Title: Date: d <br /> _ (Draw Plot Plan on-Reverse Side) .��,FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phas I routlnspection q24selailnspection <br /> Inspection By <br /> Date Inspection By 5Date G 26 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> L FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> l <br /> OTHER <br /> r . <br /> OTHER <br /> $� � -S g Issuance Date Mailed Delivered <br /> �-� <br /> Received by pate Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />