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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL A <br /> tom' ENVIRONMENTAL. HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE - <br /> WATER U LITY - <br /> Applicationisherebymadet�aqin <br /> in Local Health Distn tforap I oconstructand/or install the work,herein described.This application is <br /> made in-compliance with�Santy Ordinance N . 1862 and the rules and regula pnsA t�San Joaquin Local Health District. <br /> Exact SiteAddress t m 1'L Na eWl e' p "a 'City/To4vn` <br /> Owner's Name d_4 -C o Phone <br /> Address 6 , City ,�,Ii� s" L <br /> Contractor's Name W- License# /fa 914 Business Phone` <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes C _— No <br /> TYPE OF WORK (CHECK): NEW WELL❑f r DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - L ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION X PUMP REPAIR❑ �1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field - ti ! Cesspool/Seepage Pit Other s <br /> Property line Private Domestic Well Public Domestic Well - t <br /> INTENDED USE TYPE OF WELL <br /> ❑-INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> t4 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 <br /> ❑ GEOPHYSICAL > Surface Seal Installed By: <br /> PUMP INSTALLATION:r- Contractor <br /> Type of Pump r H.P. li a <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP A P*WA ® State Work Done LO-- t in_ 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ; <br /> Describe Material and Procedure <br /> e r <br /> 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 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 certifles 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 call for a Grout Inspection r r o routing d a 1i a1 inspection. ' <br /> Signed XlJ� t� le: Date: �JAre` � <br /> (Draw Plot I n on Reverse Side) # <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P se"Finalpectionlnspection•By' Date ry Inspection BywADate <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 I] July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUN4DUECHECKE101 <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuarfoe Date Mailed Delivered <br /> ,APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> ' t <br />