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v-caac- riucn uuannraac.. r.aiMcny _W119Ficacv. [)c uuIc IU <br /> FOR OFFICE USE: APPLICATION <br /> (--�;r Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 regulations of the San Joaquiry Loc I H alth District. <br /> Exact Site Address Q 0 City/Town �' <br /> Owner's Name Y a» Phone <br /> i Address all City- <br /> Contractor's <br /> ity Contractor's Nam License Business Phone !7,/ -7 <br /> Contractor's Address kms' ��<"' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fie With SJLHD? Yes� _ No c <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION @ PUMP REPAIR❑ 4 <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 /> r. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other'lnformation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contract . k.� 0, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> State Work Done " E"; 1 14J do Y <br /> PUMPER: <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 sub-contracting signature certifies the following:1 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 W'Il.call for a Grout I p i pri to g uting and.a final inspection. <br /> Signed . ? title: ��{. Date: I y l <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I % r Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspectiona III Final spection <br /> Inspection By Date Inspection EI.� Date <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE C1 EACH ❑ January 1 &Received By 3a ary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE R 494 <br /> 1 Li <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> � QC) .. <br /> e Received by Date Receipt No. Permit No. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />