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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR O. FICE USE: APPLICATION <br /> ! (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE R gryyp 7S S' Ci4ot'jOi: A �UALITY Ort .44 jr <br /> Application is hereby made too the an oaquin Lo8al Health District for a Oerr6it to con'struct and/or installLthe work.hj6in described.This application is <br /> made in compliance with San Joaquin County Ordi once No. 1862 and the rules and regula' �n/sof�,h?� San Joaquin Local Health District. <br /> Exact Site Address. o Qity/TOV4PC) <br /> Owner's Name U v, Phone. k <br /> Address fl c�,^ ,, :r, _. City:. 4 <br /> Contractor's Name 'eLicense / Business"Phoriet <br /> - <br /> Contractor's Address ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 9— No <br /> TYPE OF WORK (CHECK): NEW�W- -%� DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ I <br /> REPLACEMENT❑' J _ ' I <br /> DISTANCE TO NEAREST: 5eptiClTank ��_ � Sewer Lines Pit Privy <br /> .. Sewage Disposal Field D f Cesspool/Seepage'PitOther <br /> Property Line Private Domestic Well� Public Domestic Well ---'�-- <br /> INTENDED USE TYPE OF WELL /0 <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� M <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> R-IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal._.., <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r r t <br /> ❑ DiSPOSAL i I ❑ OTHER Other Information f 1 <br /> ❑ GEOPHYSICAL -. Surface Seal Installed By: -.. ?�t { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump' H.P. <br /> Ppnn <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: "� ❑ State Work Dane i ? <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued,' sha empl perso s s ject to workman's compensation laws of California." <br /> , • <br /> �Iw7f a rou ;n:s�'e n pri t routing and a final inspection.g, 3 <br /> Signed X Title: a ) Date: z 2 <br /> (Draw Plat Plan on Reverse Si <br /> r" <br /> FOR DEPARTMENT USE ONLY ) <br /> PHASE I t <br /> r Application Accepted By Date <br /> Additional Comments: ~i- f <br /> Phase 11 Grout Inspection # Final Inspectio <br /> ' <br /> Inspection By �� Date- Inspection B Date <br /> G'Fee IS Due: ❑ ANNUALLY El PER UNtT.' ❑ PER.SITE ❑ EACH LlJanuary 1 8 R ved By January 31 [{ July 1 &Received 8y July 31 <br /> w BILLING REMITTANCE $, REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> p a AMOUNT <br /> FEE <br /> LESS ; <br /> PRORATION -- <br /> PLUS w 'i <br /> PENALTY <br /> OTHER – <br /> F <br /> OTHER <br /> Received by Date Receipt No. Permit No. - -I Issuanob Date Mailed` - ed <br /> --APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 S TON,CA 95201_ <br />