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AppncationsWillBeProcessedWhen Submitted Properly Completed:Be Sure To Sign The Application. " <br /> FOR OFFICE USE: APPLICATION <br /> '+ <br /> [� �!�p � (For Non-Transferable, Revocable, Suspendable) <br /> !I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made iri compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address 1'✓I�ile1 a. 50tp,. °IF <br /> City/Town <br /> Owner's Name �• 1� L [ di t/ ��ba C1 <br /> I Phone <br /> Address_ � � 46 - _ City 1. <br /> Contractor's Name License# Business Phone 74-' A <br /> e <br /> Contra1tor's Address Emergency Phone <br /> Is Certi ficate of Workman's Compensation Insurance on File Wit SJLHD? Yes se No _ a <br /> TYPE OF WORK (CHECK): NEW'WELL❑ • DEEPEN ❑ RECONDITION❑ DESTRUCTION �? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage D'isp'osal Field — r <br /> g p ,Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well Q <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL i" ❑ CABLE TOOL Dia. of Well Excavation _ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia..of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing z <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION " ❑ ROTARY Type of Grout ` <br /> ❑ <br /> DIS POSAL '�IrF " ❑;OTHER Other Information <br />"s ❑ GEOPHYSICAL Surface SealInstalle y: <br /> PUMP INSTALLATION: I Contractor 0 ova., p <br /> i Type of Pump A z," H.P. <br /> PUMP RtPLACEMENT: 11State Work Done <br /> PUMP REPAIR: _ "r I1 State Work Dane .+k _ <br /> 4 3 <br /> DESTRUCTION OF WELL: Well Diameter <br /> K al <br /> T � Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <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 Paws 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, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspecti n r to r utin a d inal inspection. <br /> Signedy �tL l t Itie: /L!-C Date: <br /> (Draw Plot an on Reverse Side) <br /> "FOR DEPARTMENT USE ONLY <br /> PRASE I r 3 <br /> Application Accepted B J Date "` 3 <br /> Additional Comment <br /> ' Phase II Grout ction Pha +E: I1 nal Inspection <br /> Inspection By Date Inspection By Date <br /> iI w1001/ <br /> F, Is Due: ❑ ANNUALLY - 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receive my 31 <br /> ji <br /> BILLING REMITTANCE REMIT �( <br /> BASE EXPLANATION S <br /> DATE DATE 'REMITTED AMOUNT DUE CHECKED <br /> II AMOUNT <br /> FEE'' F <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY c <br /> fa <br /> OTHER Il <br /> OTHER 7 r <br /> I <br /> to t Received by Date i Receipt No. 3Permit No- Issuance Date Mailed Delivered <br /> • `¢` - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 <br />