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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The/Cpolli�tionr � <br /> F00i 0 A 4t USE: APPLICATION ff!! <br /> (For Non-Transferable, Revocable;Suspendable) PUMP ESL M <br /> ,Yy %rr. <br /> ENVIRONMENTAL HEALTH'PERMITl, l; <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 wit uin/� �t Ordi a No. 186 nd the` oaf d re ulations,of the San J Lo IH alts-B tr, t., <br /> Exact Site A dress �"` pz'�a� `� g City/Town �� f� <br /> Owner's Nam �9/1/—C./ j - Phone <br /> Address O L ._ " City 6 <br /> Contractor's Name �� Ui n # uess Phane <br /> Contractor's Addresses Emergency Phone C•�¢ . <br /> Is Certificate of Workman's Compensation Insurance on File With.SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 ,OTHER ❑ PUMP INSTALLATION 5---- PUMP REPAIR❑ <br /> REPLACEMENT❑ " <br /> t 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 /> D�DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED - Dia. of Well Casing <br /> C3DOMESTIC/PUBLIC. ❑ DRIVEN f 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 � -, Surfac al I stalle -� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit <br /> is issue6sr! <br /> employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contracr sub-cantraciingsignature cerlities the fallowing:"I tify that in the performance of the work forwhich this <br /> rhal! plo persons subject to workman's compe on laws of California." <br /> I w' t In ect' nor to grouting and a final inspect' n. l r <br /> Signed Title: r - Date: <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI w <br /> Application Accepted By 4Date <br /> Additional Comments: <br /> Phase II Grout Inspection P III Fin <br /> Inspection By_, ��z Date Inspection By <br /> Fee Is Dde: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janu y Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �= 0' 1 3 <br /> Received by- Date Receipt No. Permit No Is ante D to Mailed Delivered `- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />