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FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> :OMPLETE IN TRIPLICATE} WATER QUALITY <br /> ,`pplication 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 Ordina``n��Je No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Fact Site Address�r ry /� ?T�� City/Town . L G SCA Q <br /> j O —� <br /> wner's Name t Phone <br /> Address b41,4 City <br /> contractor's Name b License# Z L Business Phone <br /> ontractor's AddressEmergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> YPE OF WORK (CHECK): NEW WE ❑ ❑ <br /> L <br /> ( ) RECONDITION t?ESTRUCTIOt <br /> JELL CHLORINATION ❑ W1= L ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> 7EPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> rd Property.Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> rINDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> DOMESTIC/P�VATED 11 DRILLED Dia. of Well Casing <br /> ii ❑ DRIVEN Gauge of Casing <br /> .❑ IRRIGATION . ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 7 DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> LIMP INSTALLATION: Contractor <br /> F`. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done �- <br /> rRUMP REPAIR: ❑ State Work Done <br /> (. ?ESTRUCTION OF WELL: Well Diameter--(,j� Approximate Depth C <br /> —^� e �ibelates'aI�L>Zd_eL2�e�du�e S <br /> cls Te <br /> herebb+ certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l 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 wh ich this permit <br /> II is issued, I shall not employ any person in such manner as to become subject to workman's compensation IaWs.of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"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 /> 1 will call for Grout spection prior"routing and a final inspectio . <br /> Al _14— <br /> Igned X Title: Date: ` <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> " Application Accepted B Date 32' <br /> Additional Comments: <br /> Phase II Grout nspection aseFinal Inspection -yr� <br /> Inspection By Inspection By Q pate i z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION- DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEO Q. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Co07�- <br /> F , Received by Date .Receipt No. Permit No. Issu nce calte Mailed- Delivered, <br /> �-�.APPLICANT—RETURN ALL COPiES.TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E-HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 95201 <br />