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-Applications Will Be Processed When Submitted Properly complewo. oe aure 1U01yrr •�^rr• —. <br /> FO ,.OFFICE USE: APPLICATION <br /> F (For Non-Transferable, Revocable, Suspendable) �' PUMP&WELL V <br /> ENVIRONMENTAL HEALTH PERMIT �Z -� <br /> (COMPLETE 1N TRIPLICATE) TJ-!-.g b S cfw.T'� WATER QUALITY 20 —D�{O —d L <br /> 'Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliancelith San Joa/quin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. �✓� <br /> t Exact Site Address, I I_/ ',l p City/Town e <br /> IAs �;/ Phone <br /> Owrier's-Name <br /> } <br /> Address , <br /> � <br /> Contractor's Name ✓ u License# 2_.,67 Business Phone <br /> Contractor's AddressEmergency Phone G <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes 4-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT <br /> r DISTANCE TO NEAREST: Septic Tank rte Sewer Lines Pit Privy <br /> b Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i <br /> ❑ INDUSTRIAL 13CABLE TOOL_ Dia. of Well Excavation ; <br /> I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑,�,/DOMESTIC/PUBLIC ElDRIVEN Gauge of Casing <br /> Yd IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> F 11 CATHODIC PROTECTION 11 ROTARY <br /> Type of Grout <br /> 11 DISPOSAL <br /> El OTHER Other Information <br /> + ❑ GEOPHYSICAL Surface Seal Installed By: u11 <br /> PUMP INSTALLATION: Contractor IZAI/U ,z-1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> -State Work Done P V G 00.1 <br /> �! <br /> f PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth -t <br /> r 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 /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." C <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 calf for a Grout In5pection prior to grouting and a final inspectko �.. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTM T USE ONLY <br /> f PHASE l <br /> Date �� 1 <br /> Application Accepted By <br /> r <br /> Additional Comments: <br /> Phase fl Grout Inspection Phase Fi {Inspection <br /> Inspection By Date- - Inspection By Date <br /> i F <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv By REMi July 31 <br /> BASE EXPLANATION BILLING ]REMITTANCE' $ AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORA71ON <br /> PLUS <br /> PENALTY -- _ <br /> a <br /> OTHER <br /> OTHER <br /> 71, <br /> Permit No. ssuanc D Mailed Delivered <br /> Received by Date - - Receipt No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />