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AppKcituons wilt no rroaessea wren ouotnlneo rropeny%Amplwlec.me ours t n ogn I re rppimmion. s <br /> FOR OFFICE USE: APPLICAMN <br /> (For Non-Trans%rable,Revocabie,Suspendatite) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUAI.ITT <br /> Application is hereby made to the San Joaquin Local Health District for it permit to construct and/or install the work,herein described.This application is <br /> made In compliance with San Joaquin Coun rdi a e No.1862 a. the: . :argl rej ulafions of the SanLJ aquin Local Health District. <br /> Exact Site Address �� + City/Town ��� <br /> Owner's Name Phone - <br /> Address City <br /> Contractor's Name LicenseBusiness Phone2 <br /> _ 3Sal&lam <br /> ContracAddress Emergency Phone <br /> tors <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF.WORK(CHECK): NEW WELL❑ DEEPEN 0 RECONDITION❑ DESTRUCTION E3 <br /> N <br /> WELL CHLORINATION WELL ABANDONMENT 13 OTHER 13 PUMP INSTALLATION lir PUMP REPAIR 13 ` <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 /> 1+pnMDED USE TYPE OF,WELL <br /> E IINDUSTRO 1:., ❑ CABLE TOOL Dia.of Well Excavation <br /> 13DOMESTI PR TE` E3 DRILLED Dia.of Well Casing <br /> (3DOMESI"� 1G } ❑ DRIVEN Gauge of Casing 4 <br /> 0 IRRIGATION; 17 GRAVEL PACK Depth of Grout Seal �. <br /> ❑ CATHODIC kROTECT14N ❑ ROTARY Type of Grout_ ' �— <br /> ❑ DISPOSAL © OTHER Other InformationT4 �� <br /> ❑ GEOPHYS16kL "A, .Seal Installed y <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump . �1i�^ a .�� , H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: © State Work Done <br /> 1gE.STRUCtW OF WELL- Well.Diameter Approximate Depth'• <br /> _vescrits�e Ilfidtfd'tial Mynd Procedure <br /> ps , r r <br /> I hereby Certify that I have preth\\i ;application aYitl that the work will be done in accordance with San Joaquin+County. <br /> ordinanoes,state laws,and rules aridjogtXations of the San Joaquin Local Health District. r <br /> Houle owneror licensed*gums slgnabire the following:"I certify that in the performance of the work forwhich thislerlhit <br /> Is Issued, I shall not employ any personhn ankh manner as to become subject to workman's compensation laws of Califoks" <br /> Contractors hiring or sub-dortrecting sigiii;Sturo ioortifles the following:"t certify that In the performance of the work forwhich'this <br /> permit is issued, I shall employ persons e40ct.ito Wo*Mlip's c*Mpensoti'on laws of California." ' <br /> I will color a Grout Ins -action prior to qnig nd"a <br /> Signed T"W. Date: 3' <br /> �e <br /> (Draw,Plot Plan on Reverse Side) <br /> F DE, RTMENT USE ONLY <br /> PHASE 1 �4 <br /> Date <br /> Application Accepted By _ <br /> 1 <br /> Additional Comments: • <br /> Phase It Grout Inspection Ph e i -inspection <br /> Inspection By Date ` Inspection By ate <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT © PER SITE ❑ EAF�H `' ❑ January I A Received By Janwry 31 ❑ July 1 A Received By Jury 31 <br /> REMIT <br /> BASE EXPLANATION ,BILLING REIihTTANCE = AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ...._ �. ... . ._. '•;, �' r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' 4 <br /> 01MER <br /> OTHER <br /> i <br /> R by Data I Receipt No. Permit No. 13suence.D4te Wiled Delivered <br /> A LICANT—RETURN ALL COPIES TO: ENVIRONMSUTAL HEALTH Pl11f11TISERVICEa - 1601 E.HAZELTON AVE.,P.O.sex 2001 STOCKTON,CA 95291 <br />