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Applications Will Be Processed When Submitted Properly Completed. !P e S it a Application. <br /> FOI�:oFFIc� USE: APPLICATION( ��\vi �U1 <br /> ' r` (For Non-Transferable, Revoca � 8151e) <br /> i \:3 <br /> ENVIRONMENTAL ,4 PERM�&� �g�� PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUA � �, .. <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or gin�sltaN@fae {�I�ereindescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re tyl,atinb�rl*s: t �9aoaqujn Local Health District. <br /> Exact Site Address r Ae 4l_ gia own <br /> Owner's Name _ �4 1i./i� I�-[�tiu� Phone <br /> Ad d ress <br /> City <br /> Contractor's Name License#1413 -- Business Phone <br /> IF Contractor's Address l 3 n r _ r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ T� y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION19 PUMP REPAIR <br /> i REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank &er) { Sewer Lines /dd Pit Privy -- <br /> Sewage Disposal }elcl �� [� Cesspool/Seepage Pit Other <br /> Property Line__Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> f ❑ INDUSTRIAL ❑ CABLE-TOOL Dia. of-Well Excavation <br /> [ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ! ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ' <br /> ❑ DISPOSAL ❑ OTHER ;# <br /> Other Information <br /> ❑ GEOPHYSICAL F Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor (� <br /> I- Type of.Pump H.P. <br /> PUMP REPLACEMENT: D State Work Done U' <br /> PUMP REPAIR: State Work Done r <br /> I DESTRUCTION OF WELL: Well Diameter' Approximate Depth <br /> Describe Material and Procedure <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 laws, and rules and regulations of the San Joaquin.Locai 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 /> I is issued-l-shall-not•-employ-any-person-in-such-manner-as-to-become-subject to-workr'an'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 /> I w' call for a out spection pin r to grouting and a final inspection. <br /> Signed XTitle: [ Date: <br /> 0A <br /> 41 <br /> raw Plot Plan on Rever Side) - <br /> r. <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I I ���-_9-9- <br /> Application Accepted By D i Date2_0 <br /> i Additional Comments: <br /> ` PI ase it Grout In pection P s III Fina s ection <br /> Inspection Date �� ��/ _ Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January,1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> I BILLING REMITTANCE $ REMIT <br /> y BASE EXPLANATION r AMOUNT DUE- CHECKED - <br /> i DATE DATE. REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> lOTHER <br /> [[ OTHER C <br /> Received by Date , Receipt No. Permit No - Is uance Mate Mailed Delivered - <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - - 1601 E.HAZELTON AVE.,P.O"Box 2009 STOCKTON,CA 95201 <br />