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Applicai:4ons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.A � <br /> FOR OFFICE USE: h APPLICATION <br /> (a (For Non-Transferable, Revocable,Suspendable) I� <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 N . 1862 and the rules and regulations of the San Joaquin ocal ealth District. <br /> t Ih Glt�►• r� "� Cit l <br /> Exact Site Address City/Town � <br /> II <br /> Owner's Name I' &1a Phone I� <br /> Address City °"'"""•�� ' <br /> Contractor's Name l�� License#/13—�y.�Business Phone �� 7 <br /> 'I <br /> Contractor's Address Dk Emergency Phone , <br /> Is Certificate of Workman's Compensation Insurance on Fil Ith SJLHD? Yes_ No <br /> i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ) <br /> REPLACEMENT❑ I! d <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I j <br /> Sew ge Disposal Field ­x— Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL II <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing II <br /> U'DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing II" <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal II <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout II <br /> ❑ DISPOSAL ❑ OTHER Other Information II <br /> ❑ GEOPHYSICAL Surface Seal Installed By: IN.. <br /> PUMP INSTALLATION: Contractor Oa Af5II ; <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: R State Work Done <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth II <br /> Describe Material and Procedure <br /> II t <br /> I hereby certify that I have prepared this application ands 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 /> 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 /> r Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shaliremploy persons subject to workman's compensation laws of California." <br /> :II <br /> I wil call for a Grout Ins pecti for ro i ' g and final inspection. <br /> Signede' Itle: (PIC- Date: <br /> 1117 - II (Draw Plo an on Reverse Side) it s <br /> f <br /> FOR DEPARTMENT USE ONLY I i <br /> PHASE [ i <br /> Application Accepted By ! Jam- Dat 7 �~ <br /> Additional Comments: l II <br /> Phase II Grout Inspection h e Ili incl Inspection <br /> , - <br /> Inspection By im �C Date Inspection By Date 11 <br /> Fee Is Due: ❑ ANNUALLY , ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $Deceived By July 31 7 <br /> it BILLING REMITTANCE $ REMIT j <br /> BASE v) EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED 1 <br /> AMOUNT S <br /> FEE 1 $ <br /> LESS <br /> PRORATION I <br /> ti <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> II _ __ <br />• Received_py Date II Receipt No. Permit No. lss anc Date Mailed Delivered <br /> w 4 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON•CA 95201 <br />