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Applications Will Be Processed When Submitted Properly Completed. Be SureTosignTneAppimauon. <br /> FOR OFFICE USEr APPLICATION <br /> --ti (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , b j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 7 <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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local.Health District. <br /> Exact Site Addressl' S a� –�!'° 'tea City/Town <br /> Phone e <br /> Owner's Name j+-+j ►1_1 �'= t <br /> Addressr° g City <br /> ZR ! i <br /> Contractor's Name r License#�r� ''l' 1 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Zl—""PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> ❑ I PUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC. ❑ DRIVEN Gauge of Casing <br /> 11IRRIGATION ;' ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information r" <br /> 13 GEOPHYSICAL Surface Seal Installed By:All AV I <br /> N"j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump c H.P, <br /> PUMP REPLACEMENT: ❑ State Work Do t� <br /> PUMP REPAIR:,. . ❑ State Work Done <br /> DESTRUCTION OF'WELL: Well Diameter Approximate Depth r <br /> _ f Describe Material and Procedure <br /> N <br /> r <br /> «._: h <br /> 3 } <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County' <br /> t ;r}==. .ordtnances, state laws, and rules and regulations of the San Joaquin Local Health District. ` <br /> Home owner or licensed agent's signature certifies the following:1 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 Ca1ifornia," <br /> mance of the work <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perforforwhich this, <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.'. <br /> I will o'a Grout Inspection prior to grouting and a final inspection. <br /> Signe X <br /> G <br /> Title: r�1 Date: �. <br /> (Draw Plot Plan on Reverse Side) <br /> )FODEPARTMENT YSE ON <br /> PHASE I Date`�� d <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection ha final Inspectio <br /> Inspection By <br /> Date Inspection By Date-":-1110h <br /> l� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEB+pTuly.31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED- <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ` PENALTY <br /> I OTHER <br /> OTHER <br /> Date Receipt Na. Permit No. Issuance Date Mailed Deliv d - <br /> Received by " <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,,P.O.Box 2009 STOCKTON,CA 95201 <br />