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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,OFFICP-,USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELI, <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY O-W <br /> _ <br /> x Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is P <br /> made in compliance with San Joaquin County nQla t 62 d the rules and re ulations of the San J uin L c Health District. <br /> Exact Site Address/�f!e-04I&� /T• Fziin4 g City/Town �,R 9clkaAo-61 - <br /> Address - <br /> � 00 <br /> Owner's Name ��j iDY� /'r/ _ Phone <br /> Address _UI & r. ,�I I ip -�I ;n _� City <br /> i <br /> I Contractor's Name � p L.l.n License# Business Ph ne 9 <br /> Contractor's Address • Emergency Phone L <br /> Is Certificate of Workman's CompensationInsur ce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION C1 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION S' PUMP REPAIR❑ <br /> REPLACEMENT❑ i <br /> woo <br /> DISTANCE TO NEAREST: Septic Tank It90 'f` Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line (,n Private Domestic Well Public Domestic Well (of <br /> INTENDED USE TYPE OF WELL of <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11060MESTIC/PUBLIC ❑��DRIVEN Gauge of Casing e'l QC C up__P y�G _A <br /> 11 IRRIGATION ,E,-R,-GGRAVEL PACK Depth of Grout Seal .00"' <br /> IJ PROTECTION 19<0TARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Rer Information <br /> GEOPHYSICAL ce Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> 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 Local Health District. <br /> Horne er or ' ensed agent's signature certifies the following:."I certify that in the performance of the work for which this permit <br /> is i ued, I shall of employ any person ins h manner as to become subject to workman's compensation laws of California." <br /> ontractor's hiri or sub-contra ting si at a certifies the following:"I certify that in the performance of the work for which this <br /> permit is i 'sue I hall em to r s ject workman's compens tion laws of California." <br /> I �Ca <br /> a out In outi and a final inspect' <br /> Signed X Title: Date: <br /> (Draw,Plot Plan on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY , <br /> PHASE I " <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection fttjFinal Inspection �Q <br /> ' Inspection By Date ��-14-19 Inspection By Date 1 ` , <br /> r <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 /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> 1 PENALTY <br /> OTHER <br /> r OTHER <br /> r <br /> u <br /> Recesved by Date Receipt No Permit No Issuance DateMailed Oe vered <br /> APPLICANT—•RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA a 1 <br />