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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable,-Revocable, Suspendabie) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �' y,pn / WATE UAB Y ,,� l _ _o <br /> Application is hereby made too'San Joaquin Local Health District ora permit to construct and/or install the work herein described.This application is <br /> maa7de i©npcorTpliance th a?n Joaquin County OrVinance No. 1862 and the rules and regulations of the San Joaquin oval Health District. <br /> Exhc�SiteAddress 'tVJLAa )RI010 �r 1��11►�h���] City/Town ��C T�M� <br /> � IOhLQ <br /> Owner's Name Phon Hin''.) <br /> Address �• b� City <br /> rri <br /> Contractor's Name GLS License #�� Busin ss Phone <br /> Contractor's Address 16" Emergency Phone 16 I-SIP <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes •0, No <br /> TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ dLi <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 17S Sewer Lines Pit Privy V" <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well )l <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> IR 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 5L ROTARY Type of Grout I N`7T 111 <br /> 11 DISPOSAL 11 OTHER Other Information � <br /> ❑ GEOPHYSICALSurfeco gedl Instalke•d By:_i (� <br /> PUMP INSTALLATION: Y( � Contractor <br /> i Type of Pump i _ ' 3 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ❑ State Work Done <br /> PUMP REPAIR: - <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 wor 'will be done irLaccordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.•.,. z <br /> Home owner or licensed agent's signature certifies the following:"I certify thefjfi.tF�e,performance of h work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject torwgrkmans compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in-16e4 e-formance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California."' <br /> alall.for a Grou In io�rior o grouting and a final Inspection. '' , G/_Do <br /> Signed X Title: <br /> V W.N <br /> Date:` - C O <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT.:USE ONLY <br /> PHASEI ' <br /> Application Accepted By Date <br /> Additional Comments: ' <br /> Phase It Grout Inspection a III Fina nspection I Z <br /> Inspection By Date �rP �"� Inspection By Date �. <br /> v fes` h �� 5 ti.I. GLr /� a-�` ZJ/�/be <br /> Fee IS t]ue: ❑ ANNUALLY ❑ PER UNIT PER 51TE ❑ EACH ❑ anuary 1 &Received By Januar 31 ❑ July 1 &Receive July"31 <br /> .--. - REMIT _ <br /> A B€LLING REMITTANCE $ AMOUNT DUE CHECKED x <br /> .. BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> { i <br /> FEE 's <br /> LESS. <br /> D; <br /> - <br /> PRORATION <br /> PLUS --- <br /> PENALTY- <br /> OTHER <br /> � If <br /> OTHER �� 4 <br /> F S J <br /> Recved by - Date 11 Receipt No. Permit No. I suan e D to Mailed - Delivered <br /> ei { <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br /> O <br />