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Applications Will Be Processed When Submitted Properly Completed.BSureTObign IneApplIGURIVI1. I <br /> Fon OFFICE USE: APPLICATION 44 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance witty�San J quin Count Or irlce . 1862 and the I s and regulations of the San J quin Loa Health District. i <br /> Exact Site Address City/Town CC 6 <br /> Owner's Name Phone <br /> Address City rt 2 9; <br /> Contractor's Name �7 rcense Business Phone <br /> Contractor's Address acu � k� t— Emergency Phone <br /> Is Certificate of Workman's Compensation ln$urance on File With SJLHD? Yes—,K-- No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ j 1 0 <br /> DISTANCE TO NEAREST: Septic Tank T Sewer Lines Pit Privy f [^ <br /> Sewage Disposal Feld Cesspool/Seepage Pit -f Other <br /> Private Domestic WeIITQ� Public domestic Well <br /> Property Line <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— <br /> DOMESTIC/PRIVATE <br /> xcavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C1 DOMESTIC/PUBLIC 1:1 DRIVEN Gauge of Casing <br /> Oil <br /> ❑ IRRIGATION .4 GRAVEL PACK Depth of Grout Seal <br /> f ❑ CATHODIC PROTECTION A ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER -- .� ither Information "~� <br /> urface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor V <br /> �-,- �.�.,�,...:x- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 torwhich 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 pers subject to workman's compensation laws of California." <br /> I w' a for G ut I ectio o to grouting and a final inspection. <br /> Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Si ) <br /> FOR DEPARTMENT USE ONLY � <br /> PHASE I r1i n. _ 03> Dat3 z <br /> Application Accepted By '' <br /> Additional Comments. <br /> hase 11 out Inspection Phase III Final Inspection <br /> Inspection By ante U Inspection By Date <br /> Ir[ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar Received By January 31 ❑ July 1 &Recew d By REMITuly 31 <br /> r <br /> BASE EXPLANATION BILLING REMITTANC $ AMOUNT DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date� Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 -STOCKTON,CA 95201 <br />