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AI).ha <br /> dcihsWill Be Process d VVWg—nSubmltted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: J Ow APPLICATION T,C � (For No -Transferable, Revocable, Suspendable) PUMP&WELL <br /> A�- <br /> k 31 lifiONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 1�- Ds WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with/ an Jo In Co ty Ordinance No. 1862 and the rules and regulations of the San _ uin L cal HH alth District. <br /> Exact Site Address l � � + L4ze-a�� City/Town ���r pal/ <br /> Owner's Name Al <br /> Phone yn �'�✓V � <br /> Address rn A City <br /> Contractor's Name a ru License#206 Business Phone 2.07 _ <br /> � <br /> Contractor's Address ti Emergency Pho�La� A=�' �— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�_ _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IR 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 urface eal Installed By: <br /> PUMP INSTALLATION: Contractor 17x, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall empl y persons subject to workman's compensation laws of California." <br /> I wi all for Grout Ins io rior to grouting and a final inspect' <br /> Signed X Title: z - _— Date: v{-� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI tr����_ 1 <br /> Application Accepted By `-�"'�- Datey � <br /> Additional Comments: <br /> Phase It Grout Inspection Phape III Final Inspection <br /> Inspection By blQ ) n Date Inspection By Date 1 -`� <br /> w <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONBILLING <br /> DATE - REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r � I/1,31Y z 11169 Z �3'� <br /> Received 6y Dat4 Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICIES 1601 E.HAZELTON AVE.,P.O.Box 2009 _STOCKTON,CA 95201 <br />