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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> FOR OFFICE USE: APPLICATION a-0 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT j <br /> of <br /> (COMPLETE 1N TRIPLICATE) „WATER QUALITY pt' II s{k it).of �, <br /> Application is hereby made to the San Joaquin Local Health District'for a permit to construct and/or mstaII the work.herein described.This application is <br /> made in compliance w' h San Joaquin oun y Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City%Town k C <br /> Owners Name y-� °�" S` Phone` t` <br /> Address z. . 'Cit Jh "t ^ h• t" <br /> yr # <br /> Contractor's Name 1 e icense 2 7!! ' s Business Phone° y - <br /> Contractor's Address Emergency Phone.= r"'.3 +1�"• --- l <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 ❑ -- WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ , PUMP REPAIR '� F <br /> REPLACEMENT❑ / Z. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well ,/l� - 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 L �� <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 /> ❑ GEOPHYSICAL Surface Seal.Installed�By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: =❑ State Work Done f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter'— <br /> A ro mate Depth I d <br /> All 2 <br /> Describe Mate ial.and.Procedure f <br /> I hereby certify that I have prepared this a lication a d that the work will a done in accordance with San Joaquin Coun U) <br /> f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ! <br /> Y <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 rsons subject to workman's compensation laws of California.'', Q <br /> I will call for a ro nsp prior to grouting and a final inspection. <br /> Signed Title: Date:. <br /> >01 (Draw Plot Plan on Rever Side) I <br /> s <br /> �.. : FOR DEPARTMENT USE ONLY ; q� <br /> PHASE f �. 1x '...13"'� ,o►,`, <br /> Application Accepted,By �- Dat- <br /> Additional Comments: <br /> Phase 11 Grout Inspections - # Phase III Final Inspection <br /> Dat <br /> o 9-d I <br /> Inspection By <br />- Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January1'&Received By January 31 ❑ July'1 &Received By July 31 <br /> *. REMIT <br /> FBASE q "EXPLANATION BILLING REMITTANCE - $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> r <br /> LESS' <br /> PRORATION 6e V J <br /> F' ` Yf� ! <br /> PLUS - ` <br /> PENALTY Cfte-&vf o} cit d0t,11­ f/.pty <br /> OTHER CArI Qor ,>-•K if4� c Girrv�/ (,y Apnc �+ �-ov - <br /> OTHER-, r -- <br /> ��` (,t, c� uL. <br /> a ( 9.0 { <br /> l Date - a-- «-4 .Receipt No.`— ._ y. _Permit No., � a - Issuan e D to Mailed, Delivered <br /> Received by - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ . <br />