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Applications Will Be Processed When Submitted Properly Completea.tse sure Ioalgn IrirMhIJ11U0%1V19• <br /> FOR OFFICE USE: APPLICATION <br /> �M (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work.herein described,This application is <br /> made in compliance with�San oaquin Count Ordinance No. 1862 and the! ules and regulations of the San Jo uin Local Health District. <br /> Exact Site Address I"1'r� � 'a� -S6U r'` City/Town <br /> Owner's Name L 1 Phone Q�' <br /> Address — 7�9 U City _ <br /> Contractor's Name ,�I NNIn/,L,C ABS. Z0.)g +t_ License#�_ Business Phone � zS "�` � i <br /> Contractor's Address <br /> Emergency Phone S4` ~` L_. ' <br /> } �Y <br /> Is Certificate of Workman's Compensation Insu ce on File With SJLHD?„ Yes .,� No I <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN❑ s RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ / I <br /> DISTANCE TO NEAREST: Septic Tank !V Sewer Lines Pit Privy J <br /> S <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 1 <br /> PPProperty Line 61V --Private Domestic Well Public Domestic Well <br /> .V <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation- <br /> -DOMESTIC/PRIVATE <br /> xcavation DOMESTIC/PRIVATE ❑ DRILL'ED Dia; of Well Casing <br /> 13 DOMESTIC/PUBLIC C3DRIVEN Gauge of Casing r S <br /> ❑ IRRIGATION A.-GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION X ROTARY Type of Grout Q`w <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> 3 . r i <br /> Type of Pump H-P. <br /> PUMP REPLACEMENT: #❑,State.Work Done.- <br /> w PUMP REPAIR: <br /> ❑ StatI-K Irk Done,'""�� ! s <br /> to At6ter <br /> DESTRUCTION OF WELL: Well Diameter Apfproximate'Depth <br /> Describe Material and;9r0cedure <br /> I hereby certify that I 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 /> j Home owner 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 forwhich this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California.'2 <br /> I will call ora Grout Inspe tion prior-to-grouting-and-a-finalinspection.- <br /> k Signed X _� Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE;ONLY <br /> j PHASE I i (; 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> ► Ph s 111 i al Inspection <br /> f h e Il rout Inspection ` <br /> Inspection B ' Date �Intspection B Date <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑•JanuiFy,1 & �,,,.d By January 31 ❑ July I &Received By Jury 31 <br /> REMIT <br /> l BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> I J` <br /> LESS _=f <br /> ( PRORATION - <br /> a <br /> PLUS <br /> PENALTY <br /> OTHER A <br /> OTHER - r <br /> G 'g 1 1 <br /> Received by - D Receipt No. Permit No Issuance Date Mailed Delivered <br /> ,� <br /> %STOGKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Bax 2009 <br />