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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplicati5n. ; <br /> �N APPLICATION <br /> FOR OFFICE USE: - <br /> I C� (For Non-Transferable, Revocable, Suspendable) <br /> :)1 6 <br /> "b ENVIRONMENTAL HEALTH PERMIT t- I <br /> PUMP&WELL <br /> �, <br /> COMPLETE IN TRIPLICATE * ,": ATEit QUALI�If <br /> ( ) #��?F's Sic�4 �3— <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This a plication is <br /> made in compliance with San JS. /oaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. i <br /> Exact Site Address c /,� ' r P'i City/Town <br /> .0 <br /> Owners Name -� ✓�� Phone 7 <br /> Address City l <br /> Contractor's Name S License# Business Phone <br /> Contractor's Address �D� Emergency Phone a <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE;OF WORK (CHECK): NOV WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELLli CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ R <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> .w <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well MM <br /> INTENDED USE i TYPE OIF WELL <br /> ❑ INDUSTRIAL ©"CA13LE TOOL' Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN' Gauge of Casing <br /> ❑ IRRIGATION <br /> 13 GRAVEL PACK Depth of Grout Seal <br /> ❑❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout DISPOSAL <br /> " ❑ OTHER Other Information 1!t <br /> ❑ GEOPHYSICAL r face S stalled By: Ql�t <br /> f' PUMP, INSTALLATION: Contractor '. �• <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMPREPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this y. <br /> l permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I will call for a Grout Inspectio ri to rou ' g and a final inspection. <br /> Signed X CA-1i Yrj1 _ Date: ' <br /> Ij (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> + PHASE I �— <br /> Application Accepted By Date <br /> "Additional Comments: IM t <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is'Due: ❑"ANNUALLY �!� ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31- - <br /> fI BILLING REMVTTANCE $ REMIT . <br /> i, BASE EXPLANATION AMOUNT DU CHECKED <br /> 's I DATE DATE REMITTED AMOUNT <br /> FEE S�I O z. <br /> f -F3– <br /> LESS <br /> PRORATION Iw U C c6k <br /> PLUS bl <br /> PENALTY 6I '�f <br /> `. OTHER III ! <br /> OTHER II- <br /> �� 7—RFA <br /> Received by Datel - Receipt No. Permit No. Issuance Date - Mailed Delivered — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />