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Y r: Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE,USE. APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> k ENVIRONMENTAL HEALTH PERMIT /,? �p�f -7 <br /> (COMPLETE IN TRIPLICATE 9 WATER QUALITY L <br /> Application is herebymadet theSanJoaquinLpcalHealthDistrictforapermittoconstructand/orinstalltheworkherelndescnbed.Thtsapplicatlonis. <br /> tt made in compliance with n ui unty di an a No.]862 and the rules and regulations of the San Joaquin Lo al Health District. <br /> Exact Site Address ir *C(J City/Town _ l�/ <br /> 1 Cz <br /> Owner's Name _ Phone <br /> Address - City <br /> Contractor's Name License Business Phone_ ;; 2` 0 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No `-9 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION D DESTRUCTION❑ <br /> WELL CHLORINATION WELL AB NOONMENT❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ <br /> EJ <br /> REPLACEMENT❑ ( <br /> DISTANCE TO NEAREST: Septic Tank 14bd Sewer Lines Pit Privy <br /> Sewage Dispos//al F//i�tel�d Cesspool/Seepage Pit ,.1194�' ther <br /> Property Lin�(�1J'r Private Domestic Wel ,)4-Public Domestic Well_�VZ22V <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation— <br /> DOMESTIC/PRIVATE <br /> xcavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC II-DRIVEN ' Gauge of Casing <br /> # ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r 'gee r <br /> 13 CATHODIC PROTECTION ROTARY Typo of Grout <br /> t ❑ DISPOSAL OTHER Other Information —Luell <br /> ❑ GEOPHYSICAL S+lface Seal Ins d By: �Ylcsur <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> Y PUMP REPLACEMEN ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF E t Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin County!/ Y Y <br /> ordinances, state laws, 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." 6- <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, 1 shall employ persons subject to workman's compensation laws of California." A <br /> I will c r a 1 ection prior to grouting and a final inspection. <br /> Signed 51F07 rL��— Tiile: Date: lY <br /> (Draw Plot Plan on Revers ide) <br /> i FOR DEPARTMENT USE ONLY <br /> � PHASE I <br /> Application Accepted By ®C ��� Date <br /> Additional Comments: <br /> P,Wseil Grout f pection � 1 �� �P Ss III Final lxi5pection <br /> Inspection By ate f Inspection By , Bate ` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE , $ <br /> EASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No. l9suarice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.0.Box 2009 STOCKTON,CA 95201 <br />