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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> 7 ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY C�� f'7a­0� <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 San Joaquin County Ordrlarlce No. 1862 and th� rules and regulations of the San Joaq in Local Health DistrjGt. <br /> - '` ! Cit /Town . � i f <br /> Exact Site Address"--- 7--,�`�. <br /> City <br /> Cola <br /> /Town <br /> Name ZIAJO <br /> f Phone C17� <br /> Address City f�✓ <br /> t " <br /> Contractor's Name V" erase# f Business Phone o' ­144iW <br /> x <br /> Contractor's Address S� Emergency Phone _7a . .o <br /> y i <br /> Is Certificate of Workman's CompensationI s ranee on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT El - i <br /> �� � <br /> DISTANCE TO NEAREST: Septic Tank Sevier Lines Pit Privy <br /> Sewage Disposal Fielfd l I L Cesspool/Se�page Pit 6ytCr .'.Other <br /> Property Line W Private Domestic WellJDia. o <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL tr <br /> ❑ INDUSTRIAL CABLE TOOL ell Excavation❑ DOMESTIC/PRIVATE ❑ DRILLED ell Casing <br /> r; <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIO RY Type of Grout /{fes+ C F A8 iff V <br /> ❑ DISPOSAL OT Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: tractor <br /> ype o p H.P. <br /> PUMP REPLACEMENT: to Work -C <br /> PUMP REPAIR: t to Work Don <br /> DESTRUCTION OF WELL: W Diameter Approximate Depth N <br /> ibe Material d Proc ure <br /> I hereby certify that I have pre" this applicat n and t at the work will be d ce with San Joaquin County <br /> ordinances, state laws, and rul regulations f t a Joaquin Local Health Dist I <br /> Home owner or licensed agent's ign tore certifies ew g:1 certify that in the performance lie work ich this permit <br /> is issued, I shall not employ an pe on in such o become subject to workman's compen i n laws o lifornia." <br /> Contractor's hiring or sub-contr ctin signature certifies the following:"I certify that in the performance of the k forwhic this <br /> permit is issued, shall employ per ns subject to workman's compensation laws of California." <br /> I '�oall for out Inspection prior to grouting and a final inspection. <br /> f Signed X .. Title: Date• <br /> _.(Draw Plot Plan on Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE Ir <br /> Application Accepted By Date <br /> .'r Date <br /> Cel �!''_:a+� <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE #REMITTED AMOUNT <br /> FEE F ` � <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by F Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HA2.ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />