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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> C d rn� (&1-.4 (For Non-Transferable, Revocable,Suspendable) <br /> / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) 15-420 2-1r. fft 9-6EWoi-y IN <br /> ATER QUALITY � �3 described. <br /> Application is hereby made to the San Joaquin Local Health District or a permit to construct and/or instal I the work herein his application is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4 l k,owl&r 4r*X.4rP & S° 5,4 City/Town <br /> Owner's Name p&JAV011111 4110� ' Phone <br /> Address ` City 2� <br /> Contractor's Name " -2" License#/1" 7 IJl_Business Phone <br /> Contractor's Address Q Lt Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes—X No <br /> PA <br /> TYPE OF WORK-(CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ VV <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I <br /> REPLACEMENT❑ J" <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 Weil <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 /> 13 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 H.P. d <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: IN State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 <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 /> f <br /> 141 call for a Grout Inspecti n rio to Ing and a final inspection. <br /> Signed Itle: &6--e Date: <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> Application Accepted By O� Date " <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By <br /> _2-Z w �tt rt� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B nuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATfON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />