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Applications Will Be Processed When Submitted Properly Completed, BeSureToSignTheAppucauon. ) <br /> FOR OFFICE USE: APPLICATION <br /> i <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY - <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules an regulations of the San Joaquin ocal H%41tt District. a <br /> Exact Site Address -70 -ma City/Town <br /> Owner's Name Phone <br /> Address 'Nt 1. City ,' <br /> Name �-� License#-1-9_- <br /> Contractor's �..�Business Phone_. <br /> Contractor's Address 4.O Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? YesNo y <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ REO <br /> CNDITION DESTRUCTION❑ S ` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER.P PUMP INSTALLATION PUMP REPAIR rn <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy l!' <br /> Sewage Disposal 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 a <br /> -6-9©N4E-ST,I:O/P,RIVATE ❑ 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 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information s <br /> ❑ GEOPHYSICAL Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> .._... Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done -. I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ai <br /> I I <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 1 <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 d <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ! ill call for a Grout Ins e I r o gr ting an final inspection. <br /> Signed itle: P40J Date: <br /> (Draw Plo !an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> pate <br /> Additional Comments: __ <br /> i <br /> Phase II Grout Inspection Pas III Fina nspect7R,7/1 <br /> 1? � <br /> Inspection By M Date Inspection By Dat <br /> Fee IS Due: 11 ANNUALLY ❑ PER UN1T ElPER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> f: BILLING REMITTANCE $ REMIT <br /> i BASE EXPLANATION AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE S� <br /> } <br /> LESS ` <br /> PRORATION 1I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a OTHER <br /> jo, <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered I <br /> I <br /> 1601 E.HA2ELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMITISERVICES <br /> .fir- <br />