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Applications Will Be Processed When Submitted ProperlyiCompleted. Be Sure To Sign The Application. <br /> FQR OFFIPE USE: 7� APPLICATION <br /> I' (For Non-Transferable, Revocable, Suspendable) <br /> W 4, PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t <br /> (COMPLETE IN TRIPLICATE)LJITL7/fl�"Ip/A�EsWATER QUALITY <br /> Appl icatiori 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 San Jo kuin Count Ordinance No. 1862 an the rulesirpdf�gu4-ations theS n Joaquin Local Health District. <br /> P y ' UlLtJ J�C7C/Lit � <br /> Exact Site Address fi4QQ <br /> Owner's Name JL Phone <br /> AddressCity r°•� <br /> ' <br /> Contractor's Name /I .i . License#2, �G'/J� Business Phone—` <br /> Contractor's Address i` I Emergency Phone �2 V `—� <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ i PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT[] <br /> DISTANCE TO NEAREST: Se�tic Tank 4V sewer Lines Pit Privy <br /> If <br /> Sewage Disposal Field 0 Cesspo1ol/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dila. of Well Excavation <br /> NQ� <br /> DOMESTIC/PRIVATE ❑ DRILLED DIP. of Well Casing <br /> ❑ DOMESTIC/PUBLIC +❑ DRIVEN Gauge of Casing Cf1R�-�J <br /> 11 IRRIGATION tat GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> t ❑ DISPOSAL ❑ OTHER Other Information A;&0 <br /> f ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: i. ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter T Approximate Depth <br /> Describe Material and Procedure <br /> I <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 Joaquinl Local Health District. <br /> al, ii <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c II for a Grout Inspecti prior to grout! g and a final inspection. <br /> I ` <br /> Signed X Title: Date: <br /> I� <br /> (Dra47Piot Plan on RevO a Side) <br /> 'I <br /> 'I FOR DEPARTMENTUSEONLY <br /> l <br /> ,O,_-PHASE I <br /> By f' <br /> Application Accepted Date I <br /> Additional Comments:A I� <br /> A,Pf se II rout Inspection f� �'' �III Phase III Fina! Inspection <br /> Inspection By i Date ' �Y Inspection By Date <br /> a <br /> ' Fee IS Due: 13 ANNUALLY I ❑ PER UNIT ❑ PER SITE ❑ EACH fEl January 1 &Received By January 31 El July 1 &Received By July 31 <br /> r Ih BILLING REMITTANCE $ RE <br /> BASE EXPLANATION AMOUNT DUE CHECKREMIT <br /> ED <br /> II PATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I! J <br /> PRORATION ik - <br /> PLUS p �� <br /> PENALTY AAA <br /> OTHER II <br /> OTHER <br /> a <br /> Receive by Da,e I Receipt No. Permit No,iL - Is uance Dlate I Mailed Delivered <br /> APPLICANT—RETURN ALL CO IES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Bar 2009 STOCKTON,CA 95201 <br /> li jig <br />