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ted Properly <br /> �"'Applicaiions Will Be Processed when SubAmPPLICATIONp <br /> r. <br /> sFOR <br /> OtUg USE: { <br /> (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT ,,ll 9 <br />.r ! ATE YL I`� � <br /> {COMPLETE IN;TRIPLICATE) <br /> Application is hereby made to eSanJoaquinLocalHealthDistn rapermit construct and/or install the work herein described.This application is <br /> h <br /> made in compliance.with n Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> �+ f (0 � � f� City/Town l0 ! <br /> Exact Site Address <br /> ,�^ �.G i t Mf r Phone Z7_ 5 +X a <br /> Owner's Name e fi L r' <br /> Address <br /> (, /�, o- City <br /> Contractors Name <br /> Qw e ii, ll icense# Business Phone <br /> Contractor's Address Emergency Phone Il <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> {f TYPE OF WORK (CHECK): NEW WELL W DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i DISTANCE TO NEAREST: Septic Tank 0� Sewer Lines Pit Privy <br /> Sewage Disposal Fid Id Cesspool/Seepage Pit Other <br /> Property Line /d Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> e 1 <br /> ❑ NDUSTRIAL CABLE TOOL Dia. of Well Excavation t2. <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 13 IRRIGATION E] GRAVEL PACK Depth of Grout Seal _ �of <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> r Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth � <br /> DESTRUCTION OF WELL: Well Diameter <br /> I li��`' 1 Describe Material and Procedure <br /> `� 1 .�D♦ <br /> I hereby certify that l have prepared this application and 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout inspection Prior to routing and a final inspection. <br /> I Signed X : '^ <br /> � h�X// Title: 6) Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY y <br /> PHASE I <br /> Date <br /> 7 <br /> Application Accepted <br /> Additional Comments: <br /> PhaseII rout Ins ction P III in spection <br /> Inspection By ate g Inspection By w date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH ❑ January 1 8 Recelved By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IDate Receipt No.. Pel No. Issuance Hate Mailed Delivered <br /> t Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITJ$ERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />