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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION �, _-At <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMI tETE 1N TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wit an Joaqui County Ordinance No.1862 and the rules and regulatio,�sof the San Joaquin Izocal Health District. <br /> Exact Site Address e GAr L_ f FAAA,. �K/AILE ALity/Town <br /> Owner's Name CQ—CII-11 l� 0"l-A I CI Phone &O-7-LY&L - ;2,T11 <br /> Address ! City rio <br /> - <br /> Contractor's Name IAA License Business Phone <br /> Contractor's Address, .01 5p3 b A/76 11%91503 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No d <br /> TYPE OF WORK (CHECK): NEW WELL S" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line if Private Domestic Well Public Domestic Well <br /> INTENDED USE T OF WELL .7 ►. <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 i <br /> ❑ CATHODIC PROTECTION R-ROTARY Type of Grout _ <br /> ❑ DISPOSAL ((''+� ❑ OTHER Other Information _�O ISE ►���� Q, <br /> GEOPHYSICAL9"I" <br /> 1;0X1AJ COH Surface Seal Installed y:A ivD©NFD Lc Irl <br /> PUMP INSTALLATION: v Contractor <br /> Type of Pump H.P. <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 x <br /> 1 . <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin Countyp y <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 �f <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 /> I will ca r rout I ection prior to grouting and a final Inspection. <br /> Signed X Title Po/ S <br /> {Draw Plot Plan on Reverse Side} phi q fps <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE Q J <br /> Application Accepted ByC"_ Date <br /> Additional Comments: ; <br /> Phase II Grout Inspection Phapp III Final Inspection <br /> Inspection By bate Inspection By Date 1W <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED # <br /> AMOUNT <br /> EEEi <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> m_�70— s! E I�d � v sus <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> H <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEA LT PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />