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w Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.- <br /> FOR OFFICE USE: 16 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> Z- ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin(fCounty Ordinae.Rnce No. 1$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ! 4lbizrf� . ity/Town Y <br /> �� <br /> Owner's Name C Phone <br /> Address. S? 16 7WIX —_-..- City SV �7 ` <br /> Contractor's Name e.�-*" License# �3 7Z".rBusiness Phone y ra 7 !-�a <br /> .. 3 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File SJL ?- Yes_ e No C <br /> TYPE OF WORK (CHECK):. NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ j <br /> REPLACEMENT❑ Mtn E Aq-J01� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r� <br /> Sewage Disposal Field r 3' € Cesspool/Seepage Pit Other <br /> r <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 oC1 <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 Instal ed By: <br /> PUMP INSTALLATION: Contractor &04044 401.0 <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUM p4wnr: State Work Done ,��®.Pu✓!ta !�? <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 call for a Grout Inspection rip tr=an$al inspection. <br /> Signed X le: a Date: <br /> (Draw Plot an on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I `SAN W Vt.O`d� q- t D" <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection rP I Final I pectivs�a � <br /> Inspection By Date Inspection By Dated <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> i. BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ; <br /> PENALTY <br /> OTHER ; <br /> OTHER <br /> IV Vi+ J <br /> 1 <br /> Received by Date Receipt No. Permit No. I suan a bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />