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' Applications Will Be ProcessedWhen Suominea rrvpeny �Vlllrlc.c.... ....• <br />_JE.r_ <br /> ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WAFER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install theworkherein deseriba . his application is <br /> made in compliance w� a quin Co O ina e N .1862 he ru s and regulations of the Saa eaghi 4°�Llje It District. <br /> Exact Site Address ''" � � City/Town <br /> rn IA & / , f N� / Z Phone `P <br /> Owner's Name <br /> Address 1 City <br /> Contractor's Name Lnse# Business Phone aJ <br /> Contractor's Addres <br /> Emergency P ne <br /> Is Certificate of Workman's Compensation Ins nce on File With SJLHD? Yes NO — <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIQN❑ <br /> WELL CHLORINATION ❑ WELL A ANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ �r- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal,Field Cesspool/S epa a Pit Oth r -f <br /> Property Line Private Domestic Well OVO. Public Domestic Well <br /> INTENDED USE TYPE OF WELL Irti� <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation o� <br /> DOMESTIC/PRIVATE DRILLED*-- Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> OTARY 1 x Type of Grout <br /> ❑ DISPOSAL Al OTHER Other Information <br /> ❑ GEOPHYSICAL 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> 41 <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure .' <br /> t <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 ruses and regulations of the San Joaquin Local Health District: Or <br /> which this permit <br /> Homeowner or licehsed agent's signature certifies the following."'I certify that in the performance of the work for <br /> is issued, I shall not emplo;,any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contra ting Signa re certifies the following:"l certify that in the performance of the work for which this <br /> permit is ed, I shal empr1oy ersons s jest to workman's compensation laws of California." <br /> I will or a Gro 1 s e on prio o routing and a final inspects <br /> 1Date <br /> Signed X Title: <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 L Z 7� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phas Grout Inspection q P� e 1(Final inspection <br /> —A <br /> Inspection By <br /> Date inspection By �• Date ar <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recei° d By REMITuly 31 <br /> BASE EXPLANAT4ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �3 <br /> a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7779-IS � 1 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />