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It ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f <br /> r Fo.9rr; tcE USE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendable) <br /> Y ENVIRONMENTAL HEALTH PERMIT PUMP&WEI L <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 7- r <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�wiit-h�San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address _`,- Z, CC�t+�Clc.d� J ,Qyt,� City/Town <br />'. Owner's Name .L./ ' Phone <br /> Address �� .,. _ City <br /> Contractor's Name I ` License#_70Business Phone <br /> Contractor's AddressP_ i� Emergency Phone f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No d' <br /> El OF WORK (CHECK): NEW WELL DEEPEN 11RECONDITION ElDESTRUCTION❑ 411 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®_PUMP REPAIR❑ �I <br /> REPLACEMENT❑ a <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 /> ❑ II USTRIAL ❑ 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 N}} <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f,�J <br /> PUMP INSTALLATION: Contractor a . <br /> Type of Pump H.P. —~ <br /> PUMP REPLACEMENT: ❑ State Work Do(e <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> C' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County D <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 /0 <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, 1 shall employ persons subject to workman's compensation laws of California." <br /> a Grout Inspection prior to grouting and a final inspection. r� <br /> Signed Title: _ Date: 12—A, O <br /> (Draw Piot Plan on Reverse Side) <br /> h F RD TMENT USE ONLY <br /> PHASE - <br /> Application Accepted By Date ,`v/�� <br /> Additional Comments: <br /> Phase II Grout Inspection ase Final Inspection <br /> E inspection By I Date Inspection By date <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 4 <br /> REMIT j <br />' BASE ]EXPLANATIONBILLING REMITTANCE $ AMOUNT CHECKEDDATE DATE REMITTED AMOUNTDUE FEE <br /> LESS c <br />,i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> i <br /> Received.by �, Date Receipt No. Permit No. issuance Date Mailed iGered <br /> 1APPLJCANT—RETURN ALL COPIES TO:_• .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br />