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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOW-OFFICEUSE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL o - <br /> ENVIRONMENTAL HEALTH PERMIT / �1 •gyp Fa <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wilb San oaquin o my dinance No. 1862 t ' rules and regulations of the SanJ a in Loal/ earlt�h District. <br /> Exact Site Address � �-rr.� City/T wn . �6r�`�7 <br /> f <br /> Owner's Name <br /> Address ie;, m _. <br /> L City <br /> z � Business <br /> ness PhoneContractor's Name / <br /> Contractor's Address zer Emergency Phone <br /> Is Certificate of Workman's Compensation Irtsu ce on File With SJLHD? Yes Z�__ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ - WELL:ABANDONMENT ❑ . OTHER ❑ PUMP INSTALLATION ®� PUMP REPAIR❑ <br /> REPLACEMENT❑ t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines j'4 '� Pit Privy/ <br /> Sewage Disposal Field Cesspool/Seepage Pit e Other <br /> Property-Line-1W 4- Private Domestic Well - Public Domestic Well �-- <br /> INTENDED USE ! TYPE OF WELL <br /> ❑ II DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> & DOMESTIC/PRIVATE DRILLED Dia. of Well Casing �E�G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑, GRAVEL PACK Depth of Grout Seal el <br /> W <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout .4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfac eaJ Installed B / f ' <br /> PUMP INSTALLATION: Contractor ' A <br /> Type of Pump i H.P. z— <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-r, t <br /> # I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> kA , <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 for which this. <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." �- s <br /> I will call fora Grjut I ection prior to grouting and a final inspection. <br /> Signed X Rie: �/ irzi T Date: <br /> (Draw Plot Plan on Reverse Side) <br /> �/' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date/.? <br /> Additional Comments: 4 I <br /> P�ac-,e 11 Gro,-'Anspectlon 1 � n" inspection <br /> Inspection B di/ �t' y xate }-� Inspection ByGGDate <br /> Fee Is Due: ❑ ANNUALLY .❑ PER UNIT ❑ PER SITE i❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> { REMIT <br /> BILLING REMITTANCE $ 1 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O 'O <br /> FEE,�-. <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date _ Receipt.No- -.Permit No. Issu ce Dat6 Mailed.,, Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> J <br />