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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> Slfti l &AJ- f5r"--r—(For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 40 <br /> ENVIRONMENTAL HEALTH PERMITN <br /> (COMPLETE IN TRIPLICATE) 1IIJIIe �c ly/-,0/AJER 9 1 ymoApplication is hereby made to the San JoaquinLocafHeathDistrictforaper It orYstruct stallthework h&6escribed.This application is <br /> made in compliance wf San Joaquin my Ordin ce No. 1862 nd.the Sln <br /> ules regulations of the an u �l�H^ealth District. <br /> Exact Site Address d^ City/Town � t <br /> Owner's Name Phone <br /> Address City <br /> Contractor's NameLicense#��7logly _ Business Phone aha <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation I surence on File With SJLHD? Yes Lo"' No a <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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Da er s Jh fDESTRUCTION OF WELL: Well Diameter Approximate�De(hDescribe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Jordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certifythat in the performance of the work for wtis issued, I shall not employ any person in such manner as to become subject to workman's compensation law "Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the wospermit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: r /�r eQZIL CZAC Date �, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI I 1 / <br /> Application Accepted By re-CA ( Date 1 <br /> Additional Comments: <br /> P}�h�s I Grout Inspection a III F' al Inspection <br /> Inspection By ! Date Inspection ByZJ��� <br /> Fee Is bue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &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 /> �a <br /> 145 <br /> FEE S B �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 03 ?� i <br /> Received by Date Receipt No. Permit No. ipsuancef Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />