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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign Thetior} � � �� <br /> FOR OFFICE USE: APPLICATION f <br /> (For Non-Transferable,Revocable,Suspendable) PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMIT �J 117A UIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEAL-M DISTRICT <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 in compliance with San Joaquin County Ordinance No. 1862 nand the rule and regulations of the San J aquiin Loc$I Health District. <br /> Exact Site Address JVf:lJ A*IJS " 7� ".o—�.�{ .C� ARTA U� 4 4 Q it, 4_1 ��n � <br /> Owner's Name <br /> BUZ R z i C, H E x/ &�fy� s�v�G(Z Phone_6�?R— 7,,c nt <br /> Address _,Ao67.5 Z, 7 J4O N/ p Q City <br /> Contractor's Name • c- , License#J4W Business Phone 11;,60©-7ZQ 7 <br /> Contractor's Address ole)3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes AIM No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION IB PUMP REPAIR El <br /> REPLACEMENT❑ <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 /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor F .a l <br /> Type of Pump S11bH.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 <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." <br /> Iv#WcallforaG t In ction prior to grouting and a final inspection. <br /> Signed X Title: Date: Imo/ <br /> (Draw Plot Plan on Reverse Side) <br /> FO=DEPARTMENT NLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> P II Grout Inspection h e 111 Final Inspection .. <br /> Inspection By Date Inspection 6I DMk <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Q EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION I; <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> Received by ate Receipt No. Permit No. Issbance 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 />