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-=— =, Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOP OFFICE USE: APPLICATION �] <br /> y" (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance with ani-Joaquin Cou ty Ordinance No.r1862 and the rules and regulations of the San J uin ocal Health District. <br /> Exact Site Address City/Town qq <br /> Owner's Name Phone ,"— <br /> Address r City r <br /> A4,4 Business PhoneContractor's Na <br /> License# <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Innre on File With SJLHD? Yes � No <br /> [EP, <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN 11 RECONDITION 13 DESTRUCTION s <br /> WELL CHLORINATION ❑ -WELL ABANDONMENT C1OTHER 11PUMP INSTALLATION Lr PUMP REPAIR❑ <br /> REPLACE=MENT❑ cc .0 DISTANCE TO NEAREST: Septic Tank J� Sews Lines O�Q lip, <br /> Privy <br /> Sewage Disposal Field 14<o Cesspool/Seyage Pit . . Other i <br /> Property Linerivate Domestic Well _;Z!r_0� Public Domestic Well- <br /> INTENDED USE TYPE OF WELL N <br /> ❑,.,,�I USTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> U DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Se–151L <br /> ❑ IRRIGATION ❑ QPAVEL PACK Depth of Grout Seal ` sQ r <br /> ❑ CATHODIC PROTECTION 2 ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A A41,01 <br /> Type of Pump H.P.,Y ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑iState Work Done <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 San Joaquin County <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:"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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wil all fora Grout s tion prior to grouting and a final inspection. ` <br /> Ole <br /> Signed )C Title: _ Date: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date mow/ <br /> Additional Comments: <br /> h II Grout Inspectiont! has III Final Inspection <br /> Inspection By Date , �p Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 " <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - AMOUNT DUE CHECKED <br /> }� DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS <br /> PRORATION - { <br /> PLUS <br /> PENALTY * .. <br /> OTHER <br /> OTHER <br /> Received by Dat4 Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL KEALTK PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA SS201 <br />