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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FORFICE USE:.."' l APPLICATION <br /> [orkKe !fa i 0 .(For Non-Transferable, Revocable,Suspendable) <br /> 9_ PUMP&WELL <br /> -�� EENVIRO, MENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) C A7ER QUALITY �~ <br /> Application is hereby made to the San Jo c I ealthDistrictor ructand/or install the work herein described.This application is <br /> made in compliance uln regulations of the San Joaquin Local Health District. <br /> Exact Site Address ity/Town. <br /> Owner's Name SA ✓ Phone <br /> Address 3 ► �(! �Yt d.0 City - <br /> 1 ?6 <br /> Contractor's Name a- License#r93-7Business Phone <br /> Contractor's Address gR gA ii Emergency Phone <br /> ` 1s Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑. RECONDITION 1:1 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑' OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 4 <br /> REPLACEMENT❑ a t <br /> DISTANCE TO NEAREST: Septic,Tank " – Sewer Lines Pit Privy <br /> Sewage Disposal Field` -_--••�Cesspoot/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 /> ' R§ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout G <br /> ❑ DISPOSAL C1 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: # <br /> PUMP INSTALLATION: Contractor Is'l t <br /> - Type of Pump . �'ea�•►�eA✓ t G H.P. ri)+ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> y PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> z.. 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 /> art. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work fc rwhich 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 hiringor sub-contracting signature certifies thelollowin�I e of that'in.t1te performance of the work for which this <br /> ft fd g:,< Y p <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ,= I will call for a Grout Insp do prior-tQ routing and a final inspection.-' <br /> Signed Title: Date: <br /> t' Or (Draw P01 Plan on Reverse Side) <br /> c - <br /> � F DEPARTMENT USE ONLY <br /> PHASE / <br /> ` Application Accepted By Dat%�y4 � <br /> Additional Comments: <br /> Phas t r spectionPas I Inspection <br /> Ih Inspection By V Date Inspection By �ia1� Date <br /> Fee Is Due: ❑ ANNUALLY"' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> jREMIT <br /> BASE EXPLANATION BILLING REMITTANCE $DATE DATE REMITTED AMOUNT DUE CHECKED <br /> I - AMOUNT <br /> f FEE <br /> •^' <br /> fl LESS + ; <br /> PRORATION IVa' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ti <br /> OTHER - <br /> Leceived by Date Receipt No Permit No.U Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />