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„oaciiii Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: 0 APPLICATION <br /> J” (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ?_T Ce2-S• OL ,nJp A r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construCt and/or install the work hereiA described.This application is <br /> made in compliance with SanJoaquin County Ordinance No. 1862 and the rules-and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I yy�tl rS City/Town ATMM <br /> �y <br /> 4sr/s�l r - -.__.51 Qt0 <br /> Owner's Name Phone -- <br /> Address 4 �" City <br /> Contractor's Name License# 6�s'�7Z <br /> Business Phone <br /> Contractor's Address 40r. A Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on Fit ith'SJLHD? Yes aoO No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 4r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines . 4,/AO Pit Privy ooi. QRI_1F­" <br /> Sewage Disposal ield 140 r+ Cesspool/Seepage Pit ,A,d l2, Other �4 <br /> Property LineS Private Domestic Well AAA_ Public Domestic Well AIA <br /> INTENDED USE TYPE OF WELL 1I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 61 DOMESTIC/PRIVATE DRILLED «, Dia. of Well Casing 460 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN ` 4` Gauge of Casing <br /> ❑ IRRIGATION V GRAVEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION ROTARY Type of Grout oy <br /> ❑ DISPOSAL r'+ ❑ OTHER Other Information ©: <br /> ❑ GEOPHYSICAL Surfage Seal Installed By: <br /> PUMP INSTALLATION: Contractor S 16rit�� <br /> Type of Pump H.P. " <br /> PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter-mo 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit Q <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. k <br /> I wi=irut Ms eciion prior to grouting and a final inspection. ' <br /> Signed X Title: CJVAIAM Date: C <br /> (Draw Plot Plan on Reverse Side) <br /> F DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date4" <br /> Additional Comments: <br /> as !1 Grout Inspection PhaII! Final Inspection <br /> Inspection By Q-SL Date Inspection By Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED * AMOUNT <br /> FEE <br /> LESS <br /> s PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by L Date Receipt No. Permit No. Issuance Date Mailed Delivered is <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.evx 2009 STOCKTON,CA i <br />