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Applications Will Be PMte–seed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR VFFICE US. : APPLICAtION <br /> Ir t1_1 (For Non-Transferable, Revocable,Suspendable) <br /> -� PUMP&WELL , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRI�LICATE) <br /> WATER QUA[-ITY <br /> Application is herebS�made to the San Joaquin Local Health District fora permit to, onstruct and/or install the work herein described.This application is <br /> made in compliance With 5an JoaquinCoun Ordinan No. 1862 and the rule6,and regulations of the San aquin Local Health District. <br /> Exact Site Address <br /> e .i�__ ! City/Town " <br /> Owner's Name Phone <br /> Address i' City <br /> Contractor's Name License# 36 2CMBusiness Phone -o:7 <br /> Contractor's Address Emergency Phone _ <br /> I <br /> 1Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> ' <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTI N❑ \ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER El PUMP INSTALLATIOIX PUMP REPAIR❑ <br /> [ REPLACEMENT❑ U <br /> 666 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 /> ❑ 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 /> 6 ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> r ; <br /> ❑ DISPOSAL ❑ OTHER Other Information "y <br /> GEOPHYSICAL_ _.------ --�—T� ,-— c Surface Seal I stalled By: <br /> t PUMP INSTALLATION: i Contractor r <br /> *- N 1 Type of Pump tel_% ® H.P. <br /> PUMP REPLACEMENT: - ❑ State Work Done <br /> PUMP REPAIR: { ; `'^�❑ State Work•Done ' <br /> DESTRUCTION OF WELL, Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> x <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 Taws 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 /> 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 a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> �I (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY �AIP <br /> r PHASE i 1Z zn�7 <br /> Application Accepted By Date <br /> i <br /> ' Additional Comments: <br /> i Phase li Grout Inspection /�/' Final inspection <br /> �p �7 Y <br /> Inspection By Date Inspection By �+ Date f� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT .'❑ PER S1TE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING _ REMITTANCE AMOUNT DUE CHECKED <br /> �r —•, «�� —..-.,BASE_-- _EXPLANATION... — DATE DATE REQ <br /> AMOUNT <br /> —FEE-- YuD <br /> LESS <br /> PRORAT0N ! <br /> �. PLUS r — •- <br /> PENALTY [ . <br /> 6 OTHER F <br /> OTHER <br /> 79—y37� 1 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 <br /> �� <br />