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Ati_ - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. `F <br /> Fes'OF310E USE: APPLICATION <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 the work.herein described.This application is <br /> made in compliance with S�1Joaquin County Ordina ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name D Phone S- <br /> Address o�� _ �,,.`� f'S2r! <br /> Q �, _ City — <br /> Contractor's Name License tri Business Phone <br /> Contractor's Addressfo <br /> G ~' le ith Emergency Phone <br /> Is Certificate of WorkmCompensatjon Insuran�OniSJLHD? Yes C --"" No �) <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ `- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR l <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 /> ❑., I�STRIAL ❑ CABLE TOOL ; Dia. of Well Excavation <br /> ZKOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVENGauge of Casing <br /> ElIRRIGATION ❑ GRAVEL PACK 4 Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY i' <br /> l � � Type of Grout <br /> ❑ DISPOSAL ( ❑ OTHER ` Other Information <br /> ❑ GEOPHYSICAL t � 13 Su ce Seal nstalled By: <br /> PUMP INSTALLATION: Contractors �G�X..r ' — <br /> Type of Pump - _j H.P._` <br /> PUMP REPLACEMENT: ❑ State Work Done �,, � r! X <br /> R: <br /> PUMP REPAIR: 't ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _A14. <br /> Approximate-Deptlh- <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 /> k 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 ttiat in the performance of thework 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 hiking or sub-contracting signature certifies the following:' 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." <br /> �Ir a Groutspection prior to grouting and a final inspection.;) <br /> gne :, ._ _ _ —Title:— <br /> Si date: <br /> !� l <br /> (Draw Plot Plan on Reverse Side) - 1 <br /> FOR DEPARTMENT USt=ONLY' <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout InspectionP HI.Final Inspection <br /> i <br /> t Inspection By Date Inspection By Date $� <br /> 1 1 <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 /> I BASEk EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> t <br /> AMOUNT <br /> FEE S 4 <br /> L415 <br /> LESS 1 <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4s 4 <br /> Received by Date Receipt No. - Permit No. I suance Date - Mailed Del ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. oz 2009 STOCKTON,CA 9521 <br /> „a 0 <br /> � r <br />