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Applications Will Be ProcessedWhenSubmitted Properlycompieiea. oe aure I algn Incf.JJN1011W11.FOR OFFICE usE: APPLICATION ., 71F—�FVV y (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with$an Joaquin Cou ty rdinance No.1892 and t p le�.and regulations of the San Joayuip Loczal Health District. <br /> Exact Site Address df (�' `�' ern <br /> C pity/Town - �+ze- G� <br /> Owner's Name to Phone Y 0 <br /> Address City c <br /> Contractor's Name License# SIT Business Phone 7 O <br /> Contractor's Address 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST:—.Septic-Tank. - Sow er,L n_ps� Pit Privy <br /> Sewage Disposal Field - `s -'t raw Cesspool/Seepage Pit Other <br /> PAW+'9 v7 Property Line Private Domestic Well Public estic�lvell <br /> INTENDED USE TYPE OF WELL -yd ,� f 7 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Wellc v tion <br /> )(DO.MESTIC/PRIVATE El DRILLED Dia.;,of Well I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> -©CATHODIC PROTECTION ❑ ROTARY Type of Grout-° <br /> ❑ DISPOSAL ❑ OTHER Oth)?r Informati <br /> ❑ GEOPHYSICAL_ Surface Seal I stall By: P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> )JMPREPLACEMENT: ❑`State Work Done <br /> I;nePtlMP REPAIR: .a 1-+ I sa.. - State Work Done { <br /> ' DESTRUCTION OF WELL: `Well Diameter 11, - Aapro imate Depth' <br /> / D scribe Material and Pprocedure ��r1 * + �+ c�t'a+7 Q r aNr� r tf• <br /> Yher`CS!^a A b -we ee T I <br /> S4 � cu O &�`r � S ur`"�adf <br /> I , I hereby certify that I have prepared this application and that the w&rk-w'll be4done,lrS acb'o72i`ance with San Joaquin County <br /> ordinances, state laws, and 'rules and regulations of the San Joaquin Local Heafth-aMrict. i <br /> 1 <br /> Homeowner or licensed ageht's'signature certifies the following:"I certify that in the performancelof the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject o workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certifyFthat in the perfor�ance of the work for which this 1 <br /> permit is issued, I shall employ persons subject to workman's compensation, 'aws of California.l" K) <br /> I call for a G Ins, ectian rior rooting <br /> and a final 1nst5ectionr - " { <br /> Signed Title: ] Date: e/ <br /> ' ;p 3A7W <br /> &6raw Plot Plan on Reverse Side) <br /> ,i•� T t <br /> FOR EPART ENT USE ONLY "- <br /> PHASEI <br /> Application Accepted By-- Date <br /> 7 Additional Comments: <br /> Ph se II Grout Inspection �ha III ' I Inspection <br /> Ph <br /> By By Date Inspection Date <br /> a <br /> Fee Is Due: 13 ANNUALLY PER UNIT ❑ PER SITE EACH El January 1 &Received By January 31 ❑ July 1 $Received 8y July 31 <br /> i REMIT <br /> s BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> § BASE EXPLANATION DATE DATE REMITTED <br /> F AMOUNT <br /> i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. k Isuance bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />