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f Applications Will Be Processed When Submitted Properly Completed, Be Sure To SignTheApplication. <br /> 'r FOR OFFICE USE: l APPLICATION ' <br /> C6�0/& (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> r . <br /> OMPLETE IN TRIPLICATE) WATER QUALITY <br /> (C <br /> Application is hereby made to the San Joaquin Local Health District4forapermit toconstruct and/or install the work hereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Or inance No. 1862 and t e rules+and regulations of the San Joaquin LcIft Health District. <br /> Exact Site Address �'� City/Town <br /> Owner's Name ig <br /> �P '` ' Phone <br /> Address City':' <br /> Contractor's Name a License#_%��- _j kTu ess Phone 3 2. -76 7 <br /> ( Contractor's Address �' <br /> ` a Emergency Phone` " ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes_ _ __ No fi <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑-^ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REP <br /> AIR❑ ± <br /> REPLACEMENT❑ i �. ,�•„ ... 011 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _�' =--Cesspool,/Seepage Pit Other <br /> Property Line Private DomesticWellPublic Domestic Well ~•1 <br /> INTENDED USE F TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> 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 f <br /> S <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 1 Surface Seal Ins lied By: <br /> PUMP INSTALLATION: Contractor w <br /> Type of Pump - G H.P. <br /> PUMP REPLACEMENT: X State Work Done <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C <br /> Describe Material and Procedure 1 <br /> i t <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 /> Home owner 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." <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, I shall employ persons subject to workman's compensation laws of California." <br /> r 'II II for a Grout Inspeclio riot t' outin nd ti I inspection. <br /> Signed Date: <br /> x (Draw Plot PI o Reverse Side) <br /> ( i FOR DEPARTMENT USE ONLY y <br /> Application Accepted By Date 7 Z <br /> ., <br /> Additional Comments: <br /> r Phase II Grout Inspections! :_ Phast III Final Inspection 7 /� <br /> I Inspection By Date "'/ Inspection By�'�� Date <br /> 1 <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> � r <br /> �FEE:S <br /> PRORATIONPLUS <br /> - <br /> PENALTY c <br /> OTHER ev V <br /> OTHER <br /> >.. —7 _ <br /> Received by – Date Receipt No.- Permit No. issuance Date Mailed' Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />