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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> _ / Itee (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittoconstrucland/orinstalithework herein described.This application is <br /> made in compliance with San Joaquin County Ordi1nance No. 882 nd the rules and regulations of the San Joaquin Local Health District. . <br /> Exact Site Address T I Un A/ <br /> ��fl� City/Town <br /> Owner's Name U,.r Phone <br /> Address AlF: City <br /> Contractor's Nam w,Jra License# 1fux l Business Phone 441116 767 - <br /> Contractor's Address A � ' AViw Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi h SJLHD? Yes_ }C No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 1-1RECONDITION❑ DESTRUCTION-13? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS O� <br /> REPLACEMENT❑ .F <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> SewageDisposal Field •Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 12-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: <br /> PUMP INSTALLATION: Contractor � <br /> A Type.of rump H.P. 3 <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> r <br /> is issued, I shall not employ any person in such manner as to become subject to workman'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 will call for a Grout In In for o gro Ing and final inspection. <br /> � F <br /> Signed tile: Date: Ilf <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i .J g— <br /> Application Accepted By Dat f <br /> Additional Comments: " <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By bate Inspection By��Nr°_ 640*- Date - <br /> a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT �? <br /> " BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT ' " <br /> j <br /> FEE <br /> LESS f <br /> PRORATION i <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by —.--- Date- - Receipt No. - Permit No. Iss once ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.14AZELTON AVE.,P.O.Box 2D09 STOCKTON.CA 95201 <br />