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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> usE: �Ar APPLICATION <br /> r (Far Non-Transferable, Revocable,Suspendable) <br /> PUMP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �.. <br /> Application'is hereby made totheSan Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is 1 <br /> made in compliance with San Jo a In County Ordinance No. 1852 and the rules and regulations of the San Jo n L al Health District. <br /> Exact Site Address Lj I F City/Town <br /> Owner's Name �� Phone <br /> Address azn City ,t <br /> Contractor's Name Incense -5Business Phone 3 6; q f 2_2 <br /> Contractor's Addresaj 9 �- ,I�� i�— .z—�"� �i�w- Emergency Phone V� /.7 9 C�)a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL PDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ <br /> -DISTANCE TO NEAREST: Septic Tank ewer Lines Pit Privy _ J <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well s t <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation { <br />' ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑, D �STIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IL's RRIGATION .❑,.,,,.,.�G,R�AVEL PACK ; �` Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION LOROTARY Type of Grout <br /> ❑ DISPOSAL "❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump N.P- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> k Describe Material and Procedure <br /> r <br /> 1_hereby certify that I have prepared this application and that the'w4k 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 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 fallowing:"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 call for a Grout Inspection prior to grouting and a final inspection. j] <br /> signed X " Title: /^ Date: f � J <br /> # (Draw Plot Plan on Reverse Side) Illi) <br /> FOR DEPARTMENT USE ONLY <br /> t ~ PHASE I <br /> s <br /> Application Accepted By Z2?dam'¢a..A44 Date �J <br /> Additional Comments: i <br /> Phase II Grout Inspection Ph III Final Inspection i <br /> Inspection By Date Inspection By Date, <br /> „ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 11 &Received By Juky 31, <br /> L -;F` - BILLING REMITTANCE g REMIT a <br /> BASE EXPLANATION PATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> i PRORATION <br />' PLUS ! <br /> PENALTY <br /> OTHER I <br /> d by Date Receipt No. Permit No.-� Iss ance ate Mailed Delivered <br /> LOCANT--RETURN ALL COPIES TO: . ENVIRONMENTAL HEALTH PERMIT/SERVICES 116011 E.HAZELTON AVE.,P.O.Box-.2009 STOCKTON,CA 95201 <br />