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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO"FF. }USE.` APPLICATION - <br /> �. (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> � * I <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application,is <br /> made in compliance with.San.Joaquin County Ordinance No.1/8 2 and theru nd regulations of the San Joa in Local Health District. <br /> Exact Site Address Z�� ,3+ �in!!e ! 12,v 4X�QL _ City/Towni07rl ,.� <br /> Owner's Name l " " Phone' <br /> Address .St City ,e2- a, c-, X536 <br /> Contractor's Name Pho <br /> License#���/� Business ne <br /> Contractor's Address Emergency"Phone` t y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> 64 <br /> TYPE OF W' ORk (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ - ''DESTRUCTION❑ Y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑,, PUMP REPAIR❑ <br /> REPLACEMENT❑ / �— } <br /> j DISTANCE TO NEAREST: Septic Tank SeyJer Lines Pit Privy <br /> Sewage Disposal Fi/ jz I)Q 1-e Cesspool/Seepage Pit ----- Other r <br /> k Property Line �_ Private Domestic Well (. Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 0-INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f-z <br /> ADOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - G S <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ! <br /> f CATHODIC PROTECTION ROTARY Type of Grout A--L CAI <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <ZA IQ� <br /> PUMP INSTALLATION: € Contractor <br /> Type of Pump H.P. D <br /> PUMP-REPLACEMENT: ❑ State Work Done 1) <br />° PUMP REPAIR: ❑ State Work Done <br /> 4 _ <br /> I DESTRUCTION OF WELL. Well Diameter " ' Approximate Depth r <br /> r. Describe Material and Procedure ' <br /> hereby certify that I have prepared this application and that the work will be'done in accordance with San Joaquin County <br /> s ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> t <br /> Homeowner or licensed agent's signature certifies the following:1 certify thavin 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 /> T <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, I shall employ persons subject to workman's compensation laws of California."; ' <br /> I a I for a Gr Ins ctio ri to grouting and a final inspection. - 1: <br /> Signed X Title: 4axey Date: crOAe <br /> j (Draw Plot Plan on Reverse S(je) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Q <br /> Application Accepted By `�" ©� Date <br />' Additional Comments: <br /> I Grout Inspection p f" k Phase III Final Inspection <br /> Inspection B Date .7 o'p 4 _1 _ Inspection.By Date l "� L"'�� " <br /> v kj <br /> ° Fee IS Due:'❑ ANNUALLY `❑tPER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janua-ry-31' ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING :REMITTANCE $ <br /> BASE EXPLANATION DATE 1 DATE REMITTED AMOVNT DVE AMOUNT <br /> CHECKED <br /> FEE 4C(3 <br /> U <br /> LESS <br /> PRORATION - <br /> PLUS -. t <br /> PENALTY i <br /> OTHER s-4- <br /> OTHER —4. - <br /> { <br /> Received by - - Date Receipt No, - Permit No. 1;issuafnee Date. Mailed Delivered' <br /> r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 - <br />