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pp Ica ons ill Be Processed When Submitted Properly.Completed. Be Sure To Sign The Application. <br /> ct USE. APPLICATION <br /> I, (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WALL <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 the work herein described,This application.is <br /> made in compliance with San Joe uin Coun di ice No. 1862 and a rules and regulations of the San Joaquin Local Health District, <br /> Exact SiteAddress L' City/Town C <br /> Owner's Name 1 Phone 2 -+ <br /> Address _ City A�-- <br /> Contractor's Nam I v / LI ense#��2 a��'I Business Phone ra <br /> Contractor's Address �� _ �� / Emergency Phone f G <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A--- No f. <br /> t TYPE OF WORK (CHECK): NEW WELL®' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C�' PUMP REPAIR❑ ` <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ---� Pit Privy <br /> Sewage Disposal Field Q / Cesspool/S <br /> /gepage Pit Other , <br /> i <br /> Property Line Private Domestic Well 3 S Public domestic Well <br /> INTENDED USE TYPE OF WELL f� 1 <br /> ,❑ I�N��STRIAL ❑ CABLE TOOL Dia. of Well Excavation l <br /> Lti DOMESTIC/PRIVATE ❑ DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f� <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION NARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information �1 /3 ` <br /> ❑ GEOPHYSICAL t Surface Seal Installed By: , <br /> PUMP INSTALLATION: Contractor <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 /> ---Ct <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 thework 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 a ersons subject to workman's compensation laws of California." <br /> - _ ill call for a Gr u J s c1 n p dor to grouting and a final inspection. <br /> S gned X t Title: ,.. Z + y C� <br /> - Date- <br /> (Draw Plot Plan on Reverse Side) , <br /> ' FOR DEPARTMENT USE ONLY 4. <br /> �PH +^• <br /> Application Accepted By Date a' ° � <br /> Additional Comments: <br /> Phase II out Inspection phase III Final Inspection <br /> I. Inspection Date Inspection By Date t. <br /> Fee Is'Due: ❑ NUAi_LY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Ree ed By July 31 <br /> BILLING REMITTANCE $ �'� ,�/ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED - - <br /> DATE DATE REMITTED - S <br /> Q AMOUNT <br /> FEE O�� s <br /> n LESS <br /> PRORATION <br /> PLUS. <br /> PENALTY <br /> r" <br /> OTHER . <br /> OTHER <br /> Received by - D to Receipt No. Permit No.. Issuance Date Mailed- Delivered <br /> - <br /> APPLICANTRETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box2009€ STOCKTON,CA 95201 �._ 4 <br />