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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION / <br /> (For Non-Transferable, Revoc e, ndable) PUMP&WELL <br /> ENVIRONME. 1% H MIT <br /> (COMPLETE IN TRIPLICATE) A; ALITY <br /> Application is hereby made to the San Joaquin Local Health tri or�permittnocctand/or install the work herein described.This application ls <br /> made in compliance with S�Joaquin County Ordinance y 8 and t %Is and reguJat�ky1s of the San oaquin Local Health District. <br /> Exact Site Address Ott" City/Town ✓ �' <br /> Owner's Name <br /> ,s `U -� 00 7 <br /> ��P �• ``� Phone <br /> Address v City_ �✓ p // c <br /> Contractor's Name `�� />umv Lyse# l��.3 3 Business Phone l 41, — !( s <br /> Contractor's Address Emergency Phorya — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ;/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ _- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTEI <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 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 /> Ty e of Pump H.P. <br /> PUMP REPLACEMENT: UState Work Done 6s-al 477 /blo, <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 6'' <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." 5 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. / <br /> Signed X le 0-/at,& g/,7 Ce Title: h7az, Date: <br /> (Draw Plot Plan on Reverse Sidc) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ! `� <br /> Application Accepted By "`�`� Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection ByDate Inspection By?_` 7- Date la—lp-moo <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> / AMOUNT <br /> FEE s✓ <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 61 ,31o <br /> V <br /> ) 2t..c 12 <br /> , <br /> Received by Date Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />