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^eviruauonsWillBe Processed When Submitted Pro - <br /> FOR7- -n <br /> PeMy Completed. Be Sure To Sign m APPLICATION g The Application. <br /> (For Non-Transferable,ReVO'caON us end <br /> p able) y <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> {COMPLETIN RIPLICATE) / <br /> Application is hereby madeto the San Joaquin Local Health District f WATER QUALITY _ ` — r <br /> made in compliance with San Joaquinr� s n ', ,r' <br /> Count Ordinance No. igfi2 and the ruies and regulattons of the San Joaquin Lo' Heal' <br /> rml o construct and/or install the work,herein described.This application is <br /> Exact Site Address'' 3 �' <br /> ' , <br /> j Health District. <br /> Owner's Name ` City/Town „ <br /> AddressV IM,, 3 ' <br /> Contractor's Name Phone rj^ Z <br /> Contractor's Address• City�` y <br /> Is Certificate of Workman's o LI ense# L�Business Phone f <br /> Emergency Phone - <br /> TYPE OF WORK (CHECK.- rnPensation Insurance on File With SJLHD? ' <br /> NEW WELL❑ -I _ Yes` No _ <br /> WELL CHLORINATION ❑ DEEPEN ❑ No <br /> ❑ .. <br /> REPLACEMENT❑ WELL ABANDONMENT ❑ ., ..OTHER ❑ DESTRUCTION❑ <br /> PUMP INSTALLATION&- <br /> DISTANCE TO NEAREST: Septic Tank PUMP REPAIR — <br /> Sewer Lines <br /> Sewage Disposal Field Pit Privy <br /> Property Line Cesspaol/Seepage Pit, <br /> INTENDED USE Private Domestic'WeiiOther <br /> ❑ INDUSTRIAL TYPE OF WELL a Public Domestic Well <br /> �D-OMESTIC/PRIVATE 11 CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PUBLIC ❑ DRILLED ' <br /> Dia. of Well Casing <br /> ❑ IRRIGATION El DRIVEN � <br /> GRAVEL PACK Gauge of Casing <br /> CATHODIC"PROTECTIONDepth of Grout Seal <br /> 13DISPOSAL ❑ ROTARY <br /> OTHER Type of Grout <br /> ❑ GEOPHYSICAL Other Information <br /> PUMP INSTALLATION- Contractor el Surface Seal installed By: <br /> PUMP REPLACEMENT:INSTALLATION- Type of Pump <br /> PUMP REPAIR: ❑ State Work Don H.P. <br /> DESTRUCTION OF WELL: - State Work Done <br /> Well Di meter <br /> ' Describe Material and ProcedureApproximate Depth !{ <br /> F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San <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 foliowin Joaquin County <br /> is issued, I shall not employ-anyg:"I certify that in the performanceof the work for which this permit - <br /> person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or submcontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit iS issued, I shall em fo l <br /> P Y persons subject to workman's compensation laws of California," <br /> I will ca r a Grout Ins tion prior to grouting and a final inspection. <br /> Signed <br /> Title: 7 r <br /> (Draw Plot Plan onDate: tC3 <br /> Reverse Side) �— <br /> PHASE I K FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: ` Date 4 / <br /> Phase II Grout Inspection r <br /> inspection By- <br /> Date n <br /> I Final Inspection <br /> a <br /> Inspection /� � <br /> Fee Is Due: 11 'ANN " ❑ PER UNIT PER Date. <br /> SITE' - ❑ EACH - <br /> } January 1 8 Received By January 31 <br /> ❑ <br /> BASE EXPLANATION � .BILLING REMITTANCE July 1 &Received By July 31 <br /> `I } DATE $ REMIT <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ,- AMOUNT <br /> CE55 - gr i- r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Received by Dateermit No. <br /> Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER MI,TPSERVlC@5.� �.►, a l I suan a Date <br /> Mailed pelCKTO <br /> 16p1 E.HAZELTON AVE.,P.O.Box 2pOg <br /> - STQCKTON_Cd 9sanr <br />