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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR GFsICE USE: r APPLICATION <br /> In;3 0 (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE.IN TRIPLICATE)��y�ofed40 <br /> WATER QUALITY <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 Ordinance No. 1862 and the rules and re la ' r s o t oa uikvr ye th District. <br /> Exact Site Address_ lxS � a �./ .._ 1�d. ity/Tn <br /> -0 a <br /> Owner's Name Phone 7r �� n <br /> r <br /> Address City 7 <br /> Contractor's Name �V_ LL �! License# d2� D,� Business Phone .` 04r Tyr J d � <br /> Contractor's Address d4 AJ& 6 Emergency Phoney^ <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes ..� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO&----PUMP <br /> NO Q} <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER C1PUMP`INSTALLATION &— PUMP REPAIR❑ y I <br /> REPLACEMENT❑ e f ` <• � _. <br /> DISTANCE TO NEAREST: Septic Tank "� Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 711 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing [� <br /> 4 DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> 1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> r Type of Pump SK 6 <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 /> 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 performanceof thework for which this permit L� <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 fallowing:"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 /> 'C <br /> I will call a rouection rior groutin a d a final inspection. L* <br /> Signed X Title: A., Date: S K t <br /> (Draw Plot Plan on Reverse Side) <br /> - 5 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> P [se 11 Grout Inspection c�i+�„1�Yd/f t OvaY,f p� Phase 11I Final Inspection <br /> Inspection By Date T�/� � Inspection Bye; ��.�----, Date � L7h- <br /> Fee Is Due-. 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ,I <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT j <br /> FEE .� r / 'A <br /> LESS <br /> PRORATION <br /> PLUSUlK r <br /> / <br /> PENALTY I ay d Y /� OL f V+4'W� a Y+-- _+ <br /> t C I hod S�-t <br /> -.;OTHER 9 i 1 <br /> OTHER 0 !_ - b! (, e_11 1 �fT ry <br /> Received by -� Date Receipt No. Permit No. Issuance Date Mailed De3ivered <br /> 2_ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES� 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />