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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The-Application. <br /> �`rFOR•?`:T CE USE: ' APPLICATION '. <br /> - (For Non-Transferable, Revocable, Suspendable) ~ <br /> - = PUMP&WELL <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance o. 1$62 and the rules and regulations of the San Joaquin o I Health District. <br /> Exact Site Address `� �,�y�.P Q P) City/Town <br /> Owner's Name Ad-am P4 T Phone <br /> Ad d ress City ' <br /> Contractor's Name c� lYi .1 _tp License# MS 7X4 Business Phone �w'3d Cs <br /> Contractor's Address ddQ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S LHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 0 DESTRUCTION❑ N <br /> 6 WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> t REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _. _Cesspoo-I/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 /> ❑ GEOPHYSICALSur ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: State Work Done C 02V tz - <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San 7_ �unty_ <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owneror licensed agent's signature certifies thefollowing:"I certify that in the performance of thework forermiis issued, I shall not employ any person in such manner as to become subject to workman's compensation lawri ; <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 /> I <br /> _Lvoll call for a Grout Inspecon`ri to gro g an a final inspection.` <br /> Signed Me: -I- Date: <br /> {Draw Plo an on Reverse Side) <br /> v <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y�J - <br /> Application Accepted By� ez4 TGA /����� Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha . III Final Inspection <br /> Inspection By Date Inspection By bate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan ary 33❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANAT3DN DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AOTL AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> OTHER <br /> G7r 7_s _ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES' 1501 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />