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i - Applications Will Be Processed When Submitted Properlycompieteo tie sure Io sign Inempprwanarn. <br /> L1 APPLICATION C� <br /> FOR OFFICE USE: r / <br /> (For Non-Transferable, Revocable;Suspendable) PUMA&WELL T <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ' Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862,and the rules nd regulations of the San Joa l e cal Health District. <br /> Exact Site Address . �/ _,4, ` 1� � ter` City/Town <br /> Owner's-Name �T Phone <br /> Address City <br /> Contractor's Name d � I- License# _4 2 Business Phone <br /> F I <br /> Contractor's Address ''"'iE ~' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - ._ No <br /> ( TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION D WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit R►ivy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line r' Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> E ❑ 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 ❑ ROTARY Type of Grout W <br /> ❑ DISPOSAL ❑ OTHER Other Information r <br /> 11 GEOPHYSICAL Surface Seal Installed By: G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump w H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 19 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �. <br /> . 1 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 /> Home ov4her or licensed agent's signature certifies ihe-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:"l certify that in the performance of the work forwhich this <br /> perm.it is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior o g u•ng d a final inspection. <br /> r Signed XIS e: Date: <br /> t� _ �! <br /> (Draw Plot P n on Reverse Side) <br /> FO DEPAR MENT USE ONLY , <br /> PHASE I ` - 7;F1` Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final inspect <br /> Inspection By Date Inspection By � <br /> Fee Is Que: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By,1uly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> k 4v DATE DATE REMITTED AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> PLUS. <br /> r PENALTY <br /> OTHER + <br /> I OTHER <br /> a�r— <br /> t - Date Receipt No - Permit No. Iss anu ce'ua�e' Mailed - Delivered f <br /> Received by <br /> ,. APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITlSERVICES 1601,E.Hp2ELTON AVE.,P.O.Boa 2009 STOCKTON,GA 05201 <br />