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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOA*-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE}�) jet Q/L�/ 'y fllo MrWATER 4Ul�LIT <br /> Application is hereby made tot eSanJoaquinLocalHealoDfstriCtforapermitidcU�n"structand/or install the work herein described.This application is <br /> nA�e in to qO pliance ith Sa aqui unty rdinance No. 186 and the rules and regulations of the SanJoaquinLocal Health District. <br /> £#J /f3 /Town l� <br /> n <br /> I <br /> Phone Owner's N <br /> 711 l <br /> Address � City <br /> A �Q- <br /> ddre <br /> Contractor's Name Sy r" t rt License#�Q Business Phone <br /> Contractor's Address i� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION[;' �Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �®// PUMP REPAIR❑ <br /> REPLACEMENT❑ r <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 /> ❑ }iVDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> !Y�OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION t ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: — <br /> i . l.lY7'fQ <br /> 1 <br /> y PUMP INSTALLATION: Contractor <br />} Type of Pump H.P. <br /> 1 PUMP REPLACEMENT: 0- - . ❑•State Work Done <br /> PUMP REPAIR: 13 State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> l hereby certify that I have prepared this application and that the work wi11 be done in accordance with San Joaquin Gounty <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I call for Grout I spe i n r or o outing and a final inspection. <br /> Signed X Title: Date: <br /> i ( raw Piot Plan on Reverse Side) <br /> OR PARTMENT�U�•S�EE ONLY <br /> PHASE I / � g0 <br /> Application Accepted By _ ,,.._. Date <br /> Additional Comments: <br /> Phase II Grout Inspection ,,// _ PhP II Final I speate <br /> Inspection By 44 <br /> Date r Inspection By �,/� Date <br /> ( Fee Is Due: ❑ ANNUALLY { ❑ PER UNIT 1'rRER SITE ❑ EACH ❑ January 1 &;Received By January 31 ❑ July 1 &Received By July 31 <br /> IT <br /> BASE EXPLANATI N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE a� <br /> LESS aw <br /> PRORATION <br /> PLUS T <br /> PENALTY <br /> OTHER ft <br /> I: <br /> OTHER <br /> I Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 .STOCKTON,CA 95201 <br />