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F _ Applications Will Be Processed When Submitted Properly Completed. BeSureToSign ineAppucanon. <br /> I FOR OFFICE USE <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> R ENVIRONMENTAL HEALTH PERMIT <br /> F (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby madetotheSan Joaquin Local Health Districtforapermittoconstruct and/or install the work hereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Health District. <br /> Exact Site Address /6/ s � City/Town <br /> I Owner's Name + Phone -3 a <br /> Address City <br /> Contractor's Name AIL I-5;Cn)L �x nse#y i�NBusiness Phone <br /> Contractor's Address + Emergency Phone 7 <br /> Is Certificate of Workman's Compensation Insurance on File With Emergency <br /> Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ( WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ 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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALrSarface'Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1 <br /> 'Type of Pump j f H.P- <br /> PUMP REPLACEMENT: fs1 State Work Done <br /> PUMP REPAIR: �" ❑ State Work Done <br /> DESTRUCTION OF WELL: s 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 San Joaquin County C <br /> ordinances, state laws, and rules and-regulations of the San Joaquin Local Health District. <br /> 17 Home owner or licensed agent's signafure certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, l 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 /> L permit is issued, I shall employ persons subject to workman's compensation laws of California." „ <br /> I will ca for a Grout llispection prior-to grouting and-a.finai inspection. C <br /> �. -c�' <br /> Signed X . -Title: 4'` Date: ��;-2�'t�� <br /> (Draw Plot Plan on,Reverse Side) <br /> FOR DEPARTMENT USE ONLY ? <br /> *� 'PHASE I .. .�`��' <br /> ! Application Accepted By� ! -��` 'QG x Date,/Z- <br /> Additional Comments: a <br /> Phase II Grout Inspection axe III Final peclion <br /> Inspection By Date Inspection 8� Se <br /> r <br /> te _ Fee Is.Due: El ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ;a <br /> A REMIT <br /> -BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE' DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ir <br /> Received by Date Receipt No. Permit No. - Iss ante Date Mailed Delivered- <br /> r APPLICANT—RETURN ALL COPIES TO:-. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1Sol-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 9_ <br />