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F)R OFFICE USE: _ [` ;,APPLICATION <br /> ( r Non- erable, Revocable,Suspendable) PUMP&WELL <br /> EDFC% 1-1 t I)RONMENTAL HEALTH PERMIT <br /> rOMA�PL_ETEIN TRIPLICATE) WATER QUALITY <br /> pplication is hereby made tothe oaquliLacaltfealt4b_idhctforapermit toconstruct and/or install thework herein described,This application is <br /> rnade in compliance with San Joagdi{1, 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> act Site Address Ljh/ City/Town <br /> wrier's Name 1-4"y f Phone 9-�12 4;Fl� <br /> Address �Z 3 . O , !��'L -- City <br /> C>)ntractors Name 4f(B License#0�— Business Phone_a_� 'S�ypY <br /> ntractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes i� No <br /> FPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> ELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> � Sewage Disposal Field Cesspoo[/Seepage Pit Other <br /> f_� Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> rINDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> rDOMESTIC/PRIVATE E] DRILLED Dia, of Well Casing <br /> IJ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> jCATHODIC PROTECTION C1ROTARY Type of Grout <br /> J DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> JMP INSTALLATION: Contractor <br /> Type of Pumprl lrVt Si H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done rF1JlLLr� ngllg <br /> tate Work Done _* �►E�-��� �-yam <br /> MP REPAIR: <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> FillI 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 /> Homeowner 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 /> I Contractor's hiring or sub-contracting signature certifies the tollowing:"i certify that in the performance of the work forwhich this <br /> permit is issued, f shall employ persons Iubjecf to workman's compensation laws of Califot•nia." <br /> 1 will call fora Grout Inspection prior to grouting and a linal inspection. <br /> Igned X Title: Date: <br /> t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Al <br /> I 1•, �I <br /> Application Accepted By_ /�� ' `� y a Date�� 71 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final inspection i <br /> Inspection Sy n� Date Inspection By Date 1- f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> } BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> #{�� LA <br /> ( !� AMOUNT <br /> FEE �r ,� A <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by !late Receipt No. Permit No. Issuance Date Mailed Delivered <br /> L- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />