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L Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> E . (For Non-Transferable,~Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct an <br /> install the work herein described.This application is <br /> made in compliance'wi h San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address , City/Town <br /> Owner's Name g Gr9 N S 7-P4' Phone <br /> ` Address &0-" _ LU , -tel T City <br /> Contractor's Name I V . License# Business Phone <br /> Contractor's Address *Q Emergency Phone <br /> Is Certificate of Workman's Compensation lnsur ce on File With SJLHD? Yes No <br /> TYPE= OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / 021 <br /> DISTANCE TO NEAREST: Septic Tank MO Sewer Lines Pit Privy {� <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property <br /> ther Property Line Private Domestic Well Public Domestic Well <br /> 1, 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 X GRAVEL PACK Depth of Grout Seal <br /> } ❑ CATHODIC PROTECTION FLROTARY Type of Groutu <br /> r ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION' Contractor <br /> t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> " PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well-Diameter _ Approximate Depth <br /> t - - _ _ .,. <br /> M Describe,Material and Procedure <br /> I hereby certify that l 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 forwhich 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 /> f Contractor's hiring`.or sub-contracting signature certifies the following:"l certify that in the performance of the work forwhich this <br /> permit is issued,,) shall employ persons subject to workman's compensation`laws of_CAliI6e6ia, <br /> � i <br /> ' T I will call for I&GroutMect,so <br /> n rior to orousing and a final inspection. <br /> 9-1 <br /> Signed X <br /> e Title: r Date: <br /> t (Draw Plot Plan on Reverse Side) <br /> • x <br /> FOR DEPARTMENT-USE ONLY`""r <br /> PHASE I <br /> Application Accepted By= -- l' `..".. --- — - - - -r- Date �' l <br /> Additional Comments: <br /> j,P S I rout Inspection Phase III Final Inspection <br /> `c Ins e`ction By Date �'� Inspection By Z�-/-52Date <br /> . ; <br /> 4 Fee Is Due"❑ ANNUALLY ElPER UNIT []'PER SITE 11EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> a FEE <br /> r� PRORATION - <br /> PLUS { <br /> PENALTY •r'-* - ry r�. �`• . <br /> OTHER :. 1_ <br /> 4: <br /> �. OTHER <br /> 1 Received by Dae - Receipt No. Permit No, Issuance Date Mailed. Delivered - <br /> APPLICANT—RETURN ALL COPIES TO:i- ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.',.P.O.Box 2009 -STOCKTON,CA 95201 <br />