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Applications Will Be Processed When Submitted Properly Competed. Be Sure To Sign The Application. <br /> FOR OFFICE-USE: APPLICATION <br /> (Far Non-Transferable, Revocable, Suspendable) / <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br />[ made in compliance with an J �'uin Co nt rdd'' 'ance No. 1862 and the rules and regulations of the San Joaquip,Lo I He/1th District. <br /> Exact Site Addresses /i�r`irr� City/Town r�7 �/mac/. <br /> Owner's Name �' ✓ �-C Phone �V <br /> Address ' Z, - City <br /> Contractor's Name License# (�� Business Phone <br /> Ci <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0 <br /> r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r <br /> Property Line -rS- Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> E <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> R' IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface I Installed B <br /> PUMP INSTALLATION: Contractor i <br /> c r <br /> Type of Pump �-- <br /> PUMP REPLACEMENT: ❑ State Work Done _ ' <br /> 1 <br /> PUMP REPAIR: ❑ State Work Done 2'S <br /> DESTRUCTION OF WELL: Well Diameter - _. _ � - . -- Approximate Depth fF <br /> Describe Material and Procedure <br /> i 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�ploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's h ring or ub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issu d, I hal e loy persons Squbject to workman's compensation laws of California." <br /> I will call If r Uf s cUP pr' o grouting and-a final inspection / <br /> _ � p7`-- ! <br /> Signed X r f Y Title: /s,T/11�1i�.c�/ Date: <br /> (Draw Plot'Plan on Reverse Side) <br /> . i <br /> FOR DEPARTMENT USE ONLY I <br /> i y <br /> I -- <br /> Application l <br /> PHASE <br /> Accepted By "�`-' `-' Date <br /> Additional Comments: <br /> Phase II Grout Inspection ^- el nal Inspection <br /> Inspection By Date Inspection By Datel <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE "❑ EACH - ❑ January 1 &Received By January 31 ❑ July`1 &Received By July 31 <br />} BILLING REMITTANCE S REMIT <br /> II BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> f AMOUNT.- k <br /> FEE 4Lfrs, 7 <br /> LESS <br /> PRORATION <br /> L#r PLUS - <br /> PENALTY <br /> OTHER _F - <br /> 111 a <br /> OTHER <br /> i <br /> Received by Date Receipt No,; permit No. Iss ante D to Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA952011 <br />