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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 /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> 1 (COMPLETE IN TRIPLICATE) - WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin C unty O dinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> f Exact Site Address 4061,0 S✓' 1, City/Town f I <br /> Owner's Name �t �� / .�/ F'� St Phone �` 7 f q <br /> AddressCity ��I <br /> Contractor's Name u i� 'License#��fFih'�-/ Business Phone d:l ;7-7k7 <br /> Contractor's Address a Emergency Phone 7 j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 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 / <br /> f ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> P IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Al ROTARY Type of GroutJ��"'�f� <br /> ❑ DISPOSAL ❑ OTHER Other Information U <br /> ❑ GEOPHYSICAL / Surface Seal Installed By: <br /> lQ <br /> PUMP INSTALLATION: <br /> Contractor u f ��ZSa.�J <br /> -3 <br /> Type of Pump 1` H.P. <br /> PUMP REPLACEMENT: © State Work Done <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter f Approximate Depth <br /> Describe Material and`.Ptocedure . <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. Q <br /> y <br /> Homeowner 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 /> i Contractor's hiring or sub-contracting signature certifies`ihe 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 I call for a Grout Inspection prior to grouting and_a final inspection. <br /> { Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I �r' Qd g <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase it Grout Inspection Phase II nspection ; <br /> ;I <br /> Inspection By ���^�+ Date ( �8a Inspection By Date E <br /> fee'ls Due: ❑ ANNUALLY ❑ PER UNIT 1:1ZiBy PER SITE ❑ EACH ❑ January 1 &ReceJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT ' <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE I 131 L L <br /> LESS 1 <br /> PRORATION' --- <br /> C PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -Dale Receipt No. Permit No. Iss ance D to Mailed Deliv ed <br /> APPLICANT—RETURN ALL COPIES TO: "ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, 95201 <br /> . - <br />