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F f. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f — , <br /> OFf}9'E USE: APPLICATION <br /> { (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL_ <br /> (COMPLETE IN TRIPLICATE) IWUAT R QUALITY <br /> ZgU IV. � <br /> Application is hereby made to the San Joaquin Local Health Distri tffo apUmittoconstructand/or install the work herein described.This application is <br /> made in/c u to with S Joaqu'n C y non No 2 and the rules and re ulations of the San aquin Local N th District. <br /> Exact 1 d e s�? ~a _ City/Town j <br /> Owner's Name Phone f <br /> Address < City <br /> Contractor's Name License# Y?"?0 VBusiness Phone-3(091-Q- � <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_� _ No <br /> i TYPE OF WORK (CHECK): NEW WELL- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r <br /> Sewage,pisposal_Field Pesspgol/Seepage PIt+ ✓f ,Other <br /> Property L'Ine�W. Private Domestic Well Public Domestic Well <br /> INTENDED USES TYPE OF WELL -� <br /> ❑ INDUSTRIAL -ABLE TOOL Dia. of Well Excavation j <br /> '5f-DOMESTIC/PRIVATE ,�❑ DRILLED Dia. of Well Casing r <br /> ❑ DOMESTIC/PUBLIC .. ❑ DRIVEN Gauge of Casing <br />{ ❑ IRRIGATION i•0,-GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION © ROTARY Type of Grout +� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ Surface Seal Installed Bv: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �-. ti-f Y.+w k H.P. <br /> PUMP REPLACEMENT: ❑ State Wo w_ f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -` ; r Approx %Depth <br /> 1 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 /> ordiL ances, state laws, and rules and regulations of the San Joaquin Local Hedit i District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance5of he work for-Which this permit <br /> 1 is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this 0- <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of�(_Cafi,fgrnia.'y r <br /> I will c 11 for a Grout In ection prior to.grotAing and a final inspection. }s g <br /> VA <br /> Signed X Date:. <br /> ` ' y (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY L <br /> �µ <br /> PHASE I � R <br /> E Application Accepted By "-- -�" O� _ Date <br /> Additional Comments: <br /> i Ph 1 Grou nspection nspection / / <br /> Inspection By-_ Date -� �O $I Inspection By Date J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ,._.....:,,,..:y,. —BASE...�...�... —EXPLANATION— �.-. DATE _ — bATE7- �REfv11TTED 'AMOUNT.DU"E '^ AMOUNTED <br />} - ... <br /> FEE <br /> LESS % <br /> PRORATION } <br /> f PLUS <br /> PENALTY ( r <br /> OTHER <br /> k OTHER <br /> ' Received by P Date Receipt No Permit No. Issuance Date _ Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br />