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ApplicationsWill 8e Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR O.FFIC€ USE: APPLICATION <br /> l (For Non-Transferable, Revocable, Suspendable) <br /> ' ENVIRONMENTAL HEALTH PERMIT PLUMP&WELL <br /> i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> j Application is hereby made to the San Joaquin Local Health Districtforapermit toconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of a Sa Joa in Local Health District. <br />! Exact Site Address r1C1o�PC�/11 C &/y �.Ql141 <br /> Owner's Name9&?X�_ t Phone <br /> Address City <br /> Contractor's Name License# r29OkZ3 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses No <br /> E <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ti <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Q <br /> REPLACEMENT❑ GI <br /> v <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field /db f 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 L1DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l <br /> ❑ IRRIGI-TION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATH�(5DIC PROTECTION �(ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: U <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I <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 a <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Ins p tion prior to routing and a final inspection. <br /> Signed X , Date: <br /> (J. raw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , / <br /> Application Accepted By Date "`-� <br /> Additional Comments: <br /> lase 11 Grout spection Pf se II! Fin ylnspection <br />' Inspection By Date 1-7--so—F d Inspection By Date <br /> F <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 ' <br /> BILLING REMfTTANCE $. REMIT - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE NF 4 V <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I - 4 <br /> OTHER' <br /> Received by lbale Receipt No. Permit No Issuance Date Mailed. Delivered <br /> i'' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 'STOCKTON,CA 95201 <br />