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0- Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSignTheApplication. <br /> FOlrOFFICE USE: APPLICATION F <br /> (For Non-Transferable, Revocable, Suspendable) " <br /> PUMP&WELL <br /> ---- ENVIRONMENTAL HEA J. TH PERMIT �° <br /> WATIR UALITYAr �� <br /> (COMPLETE IN TRIPLICATE) 9�0� fyAr' Q <br /> Application is hereby made tothe San Joaquin Local Healf`h ,strict fora permitto construct and/or install the work herein described-This application is <br /> made in compliance with San Jo a in Count Ordinanc o. 18112 and,^ ru--le//��and regulations of the S oa uin Local Health District. <br /> Exact Site Address i City/Town <br /> Owner's NameAlf 'a ILO—AAL + e �¢¢ w • Phone <br /> Address _ City. <br /> Contractor's Name icense#•�� Busin Phone <br /> Contractor's Address W � Emergency Phone <br /> Is Certificate of Workman's Compensation I,nsuran�c 'an File With SJLHD? Yes, �--�� No <br /> TYPE OF WORK (CHECK): NEW WELL u DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDON ENT ❑ OTHER ❑ P MP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ltdt <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f <br /> Property Line Private Domestic Well Public gorrlestic Well <br /> INTENDED USE ,,, TYPE OF WELL <br /> ❑ INDU TRIAL L�ASLE TOOL Dia. of Well ExcavationG� ri (f� <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 2 ��- <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4 _ <br /> © CATHObIC 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 H.P. <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 r <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 forwhich thea <br /> permit is.issued, I shall employ arsons subject to workman's compensation laws of California." <br /> I will N I for a Gro t Insp pri to grouting and a final insppd%n. <br /> Signed X Title: Dat` <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application-Accepted By Date <br /> Additional Comments: <br /> ,t /�rM <br /> Phas4 `Gr ut I actio Phjselll'Final Inspection <br /> � fnsn By ate?�~ inspection By ��- k �tDate <br /> Z , <br /> Fee Is Due:❑ ANNUALLY ❑ 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 /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OT <br /> HER I f <br /> 101316 li✓ <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.Boa 2009 STOCKTON,CA 95201 <br />