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—Applications*Will-Be Processed When Submitted Properly Completed. Be`cure.t To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> - A (For Non-Transferable, Revocable; Suspendable) y PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ! -r. . QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to con§tructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin.County O dinance No.1862 and the rules and regula ions of the San Joaquin Local Health District. <br /> Exact Site Address � . tLd City/Town ' <br /> Owner's Name 6)fG`...'.>+ Phone <br /> Address ? City= .e. � ,JiG•.h��,..__ / <br /> Contractor's Name License# � �Business Phone_ . 7` _ '+¢ . <br /> Contractor's Address ` A6Z Emergency Phone <br /> I5 Certificate of Workman's Compensation Insurance on File WiThHD? Yes No <br /> TYPE'OF WORK (CHECK): NEIN WELL❑ DEEPEN ❑ CONDITION❑ DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ J�, <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other a <br /> Property Line Private Domestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIAL , ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing19 - <br /> IRRIGATION C]-GRAVEL PACK09 <br /> Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION i ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst Iled By:'— <br /> PUMP <br /> y:PUMP INSTALLATION: Contractor OdJQaGV -1 . -_ c ` <br /> Type of Pump H.P. p F <br /> PUMP REPLACEMENT: ❑ State Work Done " "- <br /> PUMP REPAIR: State Work Done t S <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <br /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County `b. <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:1 certify that in the performance of the work-forwhich 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 /> C 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 <br /> .Wyl call for a,Grout Ins ectl no .to routi <br /> p gand-a-final-inspeclion- - -- . <br /> Signed _ file: pl^.r f Date: <br /> !If <br /> Plot <br /> an on Reverse.Side) <br /> �II <br /> �I FOR DEPARTMENT USE ONLY y <br /> PHASE I . .. <br /> Application Accepted By Date <br /> Additional Comments: <br /> r , <br /> Phase�II Grout Inspection � "`" "' � ! e III Fin <br /> Inspection By .Date Inspect' f <br /> Fee IS Due. ❑ ANNUALLY Q-PER UNIT -❑ PER SITE" ❑ EACH:- [].January 1 &Received By JanuaryREMIT <br /> 31 ❑ duly 1 &Receival By July 31 <br /> BASEI{ EXPLANATION ,:BILLING REMITTANCE I!. �$.. ... AMOUNT DUE CHECKED <br /> - V DATE DATE - REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION iI <br /> PLUS I� i <br /> PENALTY, <br /> OTHER <br /> a. w _ <br /> y ' <br /> OTHER _ .^ <br /> 3M <br /> --- Received by Date Receipt No,- -Permit No. _ Issua e D to Mailed Delivered, , r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />