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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F OFFICE USE: APPLICATION V. � <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i <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 incompliance wit an Joaquin C Imty Ordinance No. 1662 and the rules and regulations of the San Joa in Lo al Health District. ! <br /> _ _ v <br /> Exact Site Address , S1 City/Town a <br /> Owner's Name 44V! LS Phone O J z J <br /> Ad d ress City <br /> Contractor's Name 20 License#t�3 Z// Business Phone -29_ <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes, No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ It t <br /> DISTANCE TO NEAREST: Septic Tank Se wer Lines Pit Privy <br /> Sewage Disposal Feld /O�f Cesspool/Seepage Pit Other <br /> Property Line/to � Private Domestic Well s0 -F Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well CasingPVeV <br /> ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I ROTARY Type of Grout 74 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t <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 /> Homeowner 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 fpr which this <br /> permit is issued, I shall employ perso subject to workman's compensation laws of California." <br /> I wi a Gr t In ction i to grouting and a final inspection. �} t <br /> Signed X Title: / Date: // / ln, <br /> ide) <br /> (Draw Plot Plan on Revers t <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I k t l� tZl► 1•�— " 4 <br /> Application Accepted By Date <br /> Additional Comments: <br /> /IPhase 11 Grout inspection Phase III Final Inspection <br /> Inspection By Date Inspection B Date <br /> F@@ Is Due: ❑ ANNUALLY ❑ <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &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 /> FEE <br /> �3z—� <br /> LESS I <br /> PRORATION {{ <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> r <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance bate Mailed Dehvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES .1601.E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95201 <br />