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Applications Will Be ProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: AAPPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> - PUMP&WEI_f. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) r �r� TER QUALITY �t ; <br /> Application ishereby m a+ o q in Local Health District for a permit to construct and/orinstallthe work herein described.This application is <br /> made in compliance it unty Ordinance No. 1862 and the rules and regulations of the San a uin 1I I ealth District. <br /> r Exact Site Address t City/Town <br /> Owner's Name Phone - <br /> Address City 14S <br /> Contractor's Name License eBusiness Phone � <br /> -oZ <br /> Contractor's Address <br /> Emergency Phone S4#"C— <br /> Is <br /> e Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ys, No <br /> r TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> + WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ U <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines Rit Privy <br /> Sewage,Disposal Field _. _.� �Cesspool/Seepage Pitjfr, Other r <br /> Property Linerivate Domestic Well Public Domestic Well <br /> INTENDED USEf TYPE,OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL pia, of Well Excavation <br /> P-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> _ ❑ DISPOSAL ❑ OTHER Other Information �^ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _I/44_aA "Ofi.: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump er L' 11_ - _ H.P. <br /> PUMP REPLACEMENT: 11-State Work Done_ <br /> PUMP REPAIR: []`State Work Done r` <br /> I - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> h - 4 , <br /> } I hereby certify that I have prepared thWapplication'and that the work will be done in accordance-wifh San Joaquin County <br /> ordinances, state laws, and rules and regulations-pf the San Joaquin Local Health District' <br /> il A' <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 p y an y person in such manner as to become subject to workrrian'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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will II for a Grytle i n prior to gfouting and a final inspect f <br /> 1 [+ <br /> Signed X _/ f r .�� Title: �,�� .. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR D ARTMENT SE ONLY <br /> ' PHASE - <br /> Application Accepted ByDate <br /> Additional Comments: _ <br /> a e II ut Inspection Pha a NI Final Inspection p <br /> t Inspection By ate Inspection By Date J�ir�7' J 0 <br /> 9 Fee Is Due: ❑ ANNUALLY, ❑ PER UNIT bCPER SITE ❑ EACH ❑ January 1 &Received By January 31_' ❑ July 1 &Received By July 31 <br /> _ REMIT - <br /> BASE EXPLANATION .BILLING REMITTANCE $ +' AMOUNTOUE CHECKED <br /> ( DATE DATE REMITTED AMOUNT <br /> FEE a <br /> LESS 1 Ir <br /> PRORATION / <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -� OTHER <br /> P- 16L <br /> Received by Date Receipt No. _ Permit No. - Iss ante Dae - Mailed Delivered <br /> !' <br /> APPLICANT=RETURN ALL COPIES T0:.1 ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />