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Applications Will Be Processed When Submitted Properly Comp ee! tee! t d. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: APPLICATION <br /> 4 �0J& (For Non-Transferable, Revocable, Suspendable) v� <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 Orrdi rice N 1862 and the rules and regulations of the San Joaq .n Loc H alth Distr' t. <br /> �. Exact Site Address ),a a 1� Cr i el1*loris City/Town <br /> Owner's Name % 1��'� _ Phone C V <br /> Address '� ��� City e- r <br /> Contractor's Name AV License# Business Phone �L �� <br /> Contractor's Address Q Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1:1DEEPEN ❑ ECONDITION❑ DESTRUCTION❑ IX <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR 11 <br /> REPLACEMENT 1-1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines- Pit Privy <br /> Sewage Disposal Field .Gesspool/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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> [],IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION s ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> 0 GEOPHYSICAL �, ,. Surface SealIns Iled By: _ <br /> PUMP INSTALLATION: Contractor 7"7L-trJ�m l 6..�•�, . <br /> Type of Pump—^_ J� /! _ H.P. <br /> PUMP REPLACEMENT: q ❑ State Work Done <br /> PUMP PE41111111110t, 9--State Work Dorie � ° '�� <br /> DESTRUCTION OF WELL: Well Diameter .d Approximate Depth . <br /> Describe Material and Procedure <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r 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 NN <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 for which this <br /> permit is issued, I-shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspection' p " to routi and a 'nal inspection. <br /> Signed X / �� t <br /> g Itle: Date: / <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I I <br /> Application Accepted'By <br /> Additional Comments: Date <br /> Phase II Grout Inspection a Ili Final Inspection <br /> Inspection By Date Inspection By <br /> jl1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE. EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 10 AMOUNT <br /> FEE 4517 <br /> � ,,�•— <br /> LESS <br /> PRORATION y <br /> { PLUS <br /> f PENALTY <br /> Ir OTHER ° <br /> OTHER <br /> Received by Date Receipt No. -Permit No. Issuan a Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - -1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 <br /> i <br />