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TheApplicavon. <br /> f Appllcaiions Will Be Processed When Submitted Properly Completed.BeSureToSign <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> y ip ENVIRONMENTAL HEALTH PERMIT �{ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> Application is hereby made to the San cribed.This application is <br /> Joaquin Local Health District for a permit to construct and/or install the work herein des <br /> made in compliance with San Joaquin,County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> d� <br /> Exact Site Address <br /> jev, e r t City/Town <br /> Phone <br /> J <br /> Owner's Name / ��#w.�.� �.AYfj'CAlo ` '�.� h ,> - <br /> 61L�,ai r g n <br /> Address - City <br /> Contractor's Name ° ' License#�- Business Phone <br /> ' <br /> p� ,Emergency Phone _ I <br /> Contractor's Address .; <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No' <br /> o <br /> -... <br /> TYPE OF WORK {CHECK):- NEW WELL: <br /> DEEPEN ❑' RECONDITION❑ DESTRUCTION�- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El , OTHER ❑ _ PUMP INSTALLATION 6 _PUMP REPAIR❑ 6 <br /> REPLACEMENT❑ r r <br /> li - Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL N <br /> i INTENDED USE �! <br /> ❑ INWSTRIAL ! ❑ CABLE TOOL Dia. of Well Excavation <br />+ L9-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> it <br /> E] DOMESTIC/PUBLIC i� 13DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK, Depth of Grout Seal <br /> r <br /> El PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL EIOTHER Other Information ' <br /> El GEOPHYSICAL i� Surface Seal installed By: <br /> �7 <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump <br /> PUMP REPLACEMENT: y ❑ State Work Don <br /> I 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 /> snub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I �, 1 <br /> I will call for a Grout Inspectlan prior to grouting and a final inspection. <br /> c j's Title: Date: <br /> Signed <br /> � (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 I y. � - 6'f(/ Dated T <br /> Application Accepted By i <br /> Additional Comments: <br /> Phase 11'Grout Inspection Ph e I final Inspection <br /> r Inspection By . <br /> Date Inspection By ate <br /> Fee 1s Due: 11 ANNUALLY !y."" ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveEMuly 31 <br /> IT <br /> i 14 BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> -- BASE- - -'EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION I° - <br /> 1 <br /> PLUS <br /> PENALTY i9 _ <br /> OTHER !� - <br /> OTHER <br /> Received by <br /> Date #. Receipt No P.errnifNo., uance, ate Mailed Delivered,_ <br /> I`H.PERMITlSERV1GE5 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEAL <br /> 1 <br />