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� - ,.. r-, ! fcr TheApplicaxion. <br /> Application'a ill S F ssea, Wben S tb I� Properly Completed. BeSure oSign <br /> FOR OFFICE USE: <br /> ' u) '�`=� LIA`� LICATION <br /> (For Nan-Trans er ie, Revocable,Suspendable) <br /> q •�Q�� PUMP&WELL <br /> �� `E-N NMENTAL HEALTH PERMIT _ , <br /> WATER QUALITY `� IS � <br /> (COMPLETE IN TRIPLICATE) r'! ;:';;� ::�a r . •�.. � I� 7�Y�� � <br /> Application is hereby made to the San Yl Pg6ip_Local Health,Districticra permitto construct an <br /> install t ewo e e scr be is a p kation is <br /> made in compliance with San Joaquin dounty rdmance 182 and the rules and regulations of the San Joaquin Local Health District. I <br /> Exact Site Address t tZ City/Town - t <br /> Phone <br /> Owner's Name 1 <br /> Address <br /> tm . City <br /> Contractor's Name Sall �* VLicense# Business Phone Z��-S��' 1 - <br /> Contractor's Address �� - - = -�r � Emergency Phone V <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/ <br /> PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK - -Depth-of-Grout Seal - <br /> i^ ❑ CATHODIC PROTECTION �. ❑ ROTARY - _Type of Grout <br /> ❑ OTHER Other Information L <br /> 11 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor �Ht�IfVCv 1� I C7N <br /> Type of Pump Go IL H.P. <br /> � Y <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 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 s bf�ntracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is d, I sh I e',ploy persons subject to workman's compensation laws of California." <br /> I will c a Grou ecti prior to grouting and a final inspecti <br /> Signed X �. .. - <br /> Title: Date: <br /> (Draw Plot Plan-on Reverse.Si e�._ <br /> -FOR DEPARTMENT-USE ONLY <br /> PHA <br /> SEI _ <br /> - - DateF1-- <br /> Application Accepted By <br /> Additional Comments: <br /> Phase Il rout Inspection Phase III Final Inspection <br /> .. Inspection By Date <br /> Inspection By Date <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C1 January 1 &Received By January 31 El July 1 &Received By Juiy 31 <br /> REMIT <br /> TION BILLING REMITTANCE $ AMOUNT DUE CHECKE <br /> BASE EXPLAN <br /> R DATE DATE REMITTED M <br /> FEE <br /> LESS - <br /> PRORATION <br /> L <br /> PLUS ' <br /> PENALTY <br /> Ikf � <br /> OTHER <br /> f OTHER <br /> Received by <br /> Date Receipt No. Permit No. lssuanc Date Mailed Delivered <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />