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. � �+y1 <br /> Applications Will fie Processed When Submitted Properly Completed. Be Sure o �� <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT Tim WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 County Ordinance No. 1862 and the rules and regulations of the San 1�aquin L�o�calHealth District. <br /> Exact Site Address �1V�"I' hIL Orb City/Town <br /> Owner's Name 4 Phone <br /> N. <br /> 1 Address city <br /> Contractor's Name E L `� License# V6 Business Phone ?+' 7 597 <br /> i (i., <br /> Contractor's Address 'to�. , �. Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No a <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL if BANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �44 <br /> REPLACEMENT❑ I r-- <br /> DISTANCE TO NEAREST: Septic Tank 8 Sewer Lines Pit Privy <br /> Sewage pisposal 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 a <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing of <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal a �r <br /> ❑ CATHODIC PROTECTION ' ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Information <br /> ❑ GEOPHYSICAL ijSurf a Seal Installed By: r� J <br /> PUMP INSTALLATION: ,Contractor ` <br /> i f <br /> H.P. <br /> Type of Pu <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIRS' ❑ State Work Done <br /> DESTRUCTION_OF WELL: Well Diameter, Approximate Depth <br /> « r <br /> Describe Material and Procedure <br /> .r. - <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 /> Home owner or licensed agent's signature-certifies the following:"I certify that in the performance of the work for which this permit R <br /> is issued, I shall not employ any person in such manner asoto•become-subject-to work m an's-cornpen sati on laws of California." <br /> 1. <br /> ontractorIS hiring or sub-contracting signature certifies the following-.'I celtify that in the performance of the work for which this <br /> mitis issued, I shall eml ploy persons subject to workman's compensation laws of California <br /> 1 1-call for a ro 1 In i n prio to grouting and a final ins ction.js l �� � <br /> Signed X Title: ✓�~ _ ate: <br /> 3 il� (Draw Plot Plan on Reverse Side). s. <br /> 3 r <br /> I ' FOR DEPARTMENT.USE�ONLY <br /> PHASE I <br /> P Date <br /> Application4Accepted y <br /> Additional Comment <br /> I g to"1 F d t Inspection P ase 111 F' al In pectin _ p� <br /> Inspection By pe <br /> ate Insction By 1 <br /> 21 <br /> Fee IS Due:,❑ ANNUALLY PER UNIT ❑"SER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑.July 1 &Received By July,3t - <br /> I _ I _ti ..�, ,_.r REMIT <br /> BASE �� EXPLANATION BILLING REMITTANCE .r �$ a AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> a FEE € <br /> ' LESS <br /> PRORATION <br /> PLUS I� <br /> PENALTY I <br /> t II,OTHER - <br /> OTHER l <br /> S-76 <br /> Received by Date I� Receipt No, Permit No. I uance ate Mailed Delivered - <br /> APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />