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Applications Will.Be Processed When Submitted Properlycompimeo.ae oure 1 orvr,.: •�•+rr•�- I <br /> FOR OFF,f'E USE: APPLICATION n <br /> ' (For Non-Transferobl6, Revocable,Suspendable) PUMP&WELL s� , <br /> I <br /> ENVIRONWIENTAL HEALTH PERMIT r <br /> • aN <br /> (COMPLETE IN TRIPLICATE) WTae'r4J <br /> f`� > <br /> Application is herebymadetothe San Joaquin Local Health Districtforo s cta orin§tallthework herein described.This application is 0 <br /> made in compliance with San Joa uin County Ordinance No.1862 and the rules and regulations of the San J aquin Local Health District. 1 <br /> 2. <br /> City/Town a U <br /> Exact Site Address tl^ I / <br /> IrP1" G* Ct'� 3 6 2.Z <br />` Owner's Name � Phone�„ r ) <br /> Address Ce r City " a <br /> Contractor's Name • :V icense#3 �'l23Business Phone - .3 <br /> Contractor's Address Y emergency Phone z/_ No �- x� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - No <br /> TYPE OF WORK (CHECK): NEW WELL�Z DEEPEN ❑ RECONDITION 13 DESTRUCTION <br /> 11 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP iNSTALLATION25-, PUMP REPAIR❑ <br /> REPLACEMENT❑ �r ' <br /> DISTANCE TO NEAREST: Septic Tank <br /> AvO/✓Q Sewer Lines . Ale 4,4e Pit Privy <br /> Sewage Disposal��Fie��ll•d 10,0, ze Cesspool/Seepage Pit/�Dsc/6 `Oither <br /> Property Line 'tPrivate Domestic Well Fes- Public Domestic Well /u+ ) N C <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation f/ <br /> 2DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 40 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: <br /> 11 State Work Done <br />¢ DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure.-<�-y- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counly <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 /> ti 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, I shall employ persons subject to workman's compensation laws of California." <br /> k k call fora Grout In ctian prior to grouting and a final inspection. r <br /> Signed X ;Title: " Date: <br /> (Draw Piot Plan oni;Reverse Side) <br /> Q d AR ENT USE ONLY > <br /> PHASE I Dat9rs���� <br /> Application Accepted By <br /> Additional Comments: i <br /> Phase,ll Grout Ins ction Ph a I11 Final Inspecf n <br /> ., .. ' ^y ✓ tl �� Ins ection By "gate <br /> binspectioh By ate P <br /> Fee IS Due: NU El PER UNIT PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly.31. <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> �i OTHER - ' <br /> 1 43 -79 <br /> Received ty Date Rece+pt No. Permit No. Issuance Dale Mailed Delivered <br /> k <br /> }� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O:Boa 2009 �STOCKTON,CA 95201 <br />