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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. 4 <br /> FOR OFFICE USE: APPLICATION <br /> (a o )b �44 (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> {COMPLETE IN TRIPLICATE) 2 nJ6 +G- Ato— ©EER QUA ITY-� p g3 —Of�o—o <br /> Application is hereby made to the InJbagainLocal-HealthDls Ictfora-permltoconsfructand/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 Joaquin Local Health District. <br /> Exact Site Address 1 k4l& lJa 4-T4- o la ga p'+� .�' City/Town <br /> Owner's Name Aea Phone <br /> Address P. City 06ki ,rprlt <br /> Contractor's Name a License# —7A- Business Phone <br /> Contractor's Address Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance o File With SJLHD? Yes No r <br /> TYPE OF WORK (CHECK): NEW WELL DE PEN ❑ RECONDITION❑ DESTRUCTION❑ G <br /> WELL CHLO-RINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS S <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _ fiCesspool./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 —T�Y H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done&.4.eAfP-AYad� ""t <br /> 6nw�1 e Cb H� r`� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure <br /> k <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 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." 1y� <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this 4' 1 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r I will call for a/Grout Inspection prior to g uting nd a final inspection. Date: <br /> Signed X �'( ' e: � <br /> IV (Draw Plot PI n on Reverse Side) ; <br /> f FOR DEPARTMENT USE ONLY dQ„ <br /> PHASE IO/ II <br /> Application Accepted By {7 Date d <br />` Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection v t <br /> inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> t REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE PATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> It[ OTHER <br /> f OTHER <br /> V t ca 0 <br /> Received by - Date, Receipt No. Permit No. IssuanN Date Mailed Delivered <br /> �, ,. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL iiEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 95201 <br />