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ApplicationsWill BeProcessedWhen ..,e Sure To Sign The Application. <br /> FOR OFFICE USE: ffia-'i _,...%;ATI A <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 thework'heYeih dtascribed?Thii . pplication is <br /> made In compliance with 5 n,.J`oa�quin Cow m e N 2 of d the rules and regulations of the Sa quln Ls��I HW h (strict. <br /> Exact Site Address 6 " �^' T7V 7— City/Town` <br /> Owner's Nairn �' -�T U GG/ <br /> Phone <br /> Address _ City <br /> Contractor's Name P License# ` Business Ph n <br /> Contractor's Address �� T` Emergency Phone egle� <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 J4 PUMP REPAIR❑ <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 is <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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Don <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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is d, I shall em rsons subject to workman's compe on laws of California." <br /> I w' c ut Inspe tion rior to routing and a final inspec n. <br /> Signed XTi1ie: Date/tea'/ <br /> (Draw Plot Plan onfie-verse Side) <br /> FOR EPARTM T USE ONLY <br /> PHASEI <br /> Application Accepted By /Yue�^� Date l� <br /> Additional Comments: <br /> Phase II Grout Inspection �)i rnal Inspection <br /> Inspection By Date Inspection By fp -P�+� Date <br /> u <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS is <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -12,7-5 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON C <br />