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Appli Qt��n�yiFe �oessedWhenMPLICATION <br /> ted Properly Completed. BeSureTosign Ineappncallvn. <br /> FOR OFFICE USE: i !�4���}} <br /> SES 1 ( won-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> IdVF{f "MENTAL HEALTH PERMIT <br /> SAN I rl F�ICT WATER QUALITY v� <br /> k (COMPLETE IN TRIPLICATE) i [)1S <br /> Application is herebymadetothe-Sa ocalHealthDistrictforapermittoconstructand/orinstal!theworkhereindescribed.Thisapplicationl�s 't <br /> made in compliance with San Joaquin County rdinan'e No. 186 an the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address " <br /> City/Town <br /> Ji <br /> Owner's Name Phone <br /> t Address ' t Cit <br /> Contractor's Name License# Business Phone 7 ? <br /> 71 <br /> Contractor's Address 3 Emergency Phone i� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes . No {) <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El RECONDITION❑ {DESTRUCTIONII, f <br /> WELL CHLORII)IATION WELL ABANDONMENT O, OTHER.O PUMP INSTALLATION- PIM REPAIR 13REPLACEMENT 11 _- - <br /> t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 1� I Other <br /> 't Property Line-4-5-0-1 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> iF ❑ I11DUSTR1At_ CABLE TOOL Dia" of Well Excavation ~_ <br /> DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing r 'if _77 ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Jl f <br /> i ❑ GRAVEL PACK De th of Grout Seal 5 )I <br /> © IRRIGATION I t p r <br /> t ❑ <br /> CATHODIC PROTECTION 1 ❑ ROTARY cTyp,bf Grobtt �S ,- <br /> r. O.OTHER Other'lnformation <br /> ❑ DISPOSAL <br /> ❑ GEOPHYSICAL Surface Seal installed By <br /> PUMP INSTALLATION: Contractor n JAzbn, <br /> Type of Pump MI.L H.P. C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> C3 State Work Done I <br /> PUMP REPAIR: H <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari-Joaquin-County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I�`' <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of ttte;work farwfiich.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 th-Atin the performance of the work forwhich this <br /> I permit is issued, I shall employ persons subject to workma� c'ompensatiorTJaws of'�Californi." �k <br /> I will c II for a Grout Inspection prior t"routing and a final inspectio <br /> II Date: <br /> Signed X n &IN Title: F <br /> j. (Draw Plot Plan on Reverse Side) <br /> �` FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> Date <br /> Application Accepted By <br /> l �} <br /> Additional Comments: _ o� M1 <br /> - <br /> I-Ph 'll-Grout•Insp ction^ ., - "" 'P as 11-FirYal spection/G�A 4?0 <br /> gg Inspection By I ate ' Inspection By Date <br /> I 'I <br /> r <br /> E <br /> Fee Is Due: 11ANNUALLY '.❑ PER UNIT El PFR SITE El EACH 13 January 1 &Received By January 31July 1 &Received By July 31 <br /> I� BILLING REMITTANCE $ 'AREMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ¢� IN DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 11 <br /> PENALTY i� f <br /> r <br /> OTHERII I L <br /> OTHER I� �� r <br /> 7z) '5111 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> .APPLICANT—RETURN ALLICOPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES""' 1601 E.HAZELTON AYE.,P:a.Box 2009 STOCKTON,CA 95201 <br />