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Applications Will Be-Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OROG'FFICE USE: APPLICATION <br /> F - (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WPLI_ <br /> ENVIRONMENTAL HEALTH PERMIT { <br /> (COMPLETE IN TRIPLICATE) X2XU 6 Cyt ,jWATER QUALITY 177 — /00- 07 I <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 i <br /> I made in compliance with San Joaquin County Ordinanc No. 62 and the rules and regulations of the 5 Joaquin Local Health District. <br /> �itli U <br /> Exact Site Address f <br /> Phone <br /> Owner's Nam <br /> I <br /> City <br /> Address <br /> Contractor's Name License# Q Business Phone <br /> Contractor's Address S��P ma Emergency Phone. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No - <br /> t TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <br /> REPLACEMENT❑ F <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines j <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property <br /> ther 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 I ❑ DRIVEN Gauge of Casing <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION � <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout m <br /> ❑ DISPOSAL 0 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 7) <br /> ' <br /> PUMP INSTALLATION: Contractor cl <br /> 1� <br /> f Type of Pump "'t � ° H.P. 2 I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> * PUMP REPAIR: IV State Work Done �.C. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <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 for which this permit <br /> is issued, I shall not employ any person in such manner as-to_becomeF 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." I <br /> I will caI fora rZr <br /> tion prior to grouting and a final inspec ion. <br /> Signed X t �-�-tid�� Title: Date: <br /> (Draw Plot Plan on Rev rse Side) a <br /> FOR DEPARTMENT USE ONLY <br /> d <br /> PHASE I <br /> Application Accepted By Date b <br /> Additional Comments: <br /> Phase II Grout Inspection hase III Final Inspection ^ �� <br /> j. Inspection By Date Inspection By Date tf <br /> Fee is Due: ❑-ANNUAI-LY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 8 eceived ByJanuary31 ❑ July 1 &Received By July 31 <br /> REMIT 3 <br /> ` EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> t DATE - DATE REMITTED AMOUNT C <br /> I FEE ' + <br /> LESS l <br /> S PRORATION <br /> PENALTY r / �! r <br /> l� L, } <br /> fOTHER U � <br /> IF <br /> j r r i <br /> OTHER I�L+P I�6�1Q i Lv> I`keoc 744e _ <br /> Received by Date' Receipt NOL 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 />