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Applications Will Be Processed When Submitted Properly Completea.besure Io algn inefapput;auuI <br /> FAR OF USE: t APPLICATION <br /> }! (For Non-Transferable, Revocable,Suspendable) <br /> } PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqui n Local Health District for a permit to construct and/or install thework herein described.This application is <br /> made in compliance with a uin C unty OrdinaN^o. 1862 and the rules and regulations of the San Ja�yl <br /> sain L cal Heab(h District, <br /> Exact Site Address - �� '� City/Town <br /> Phone <br /> Owner's Name <br /> r1 �,�, LL- <br /> Address 5 City <br /> t� ulQ <br /> ' Contractor's Name L icense Business Phone th <br /> Contractor's Address Z. w Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL i' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ pb <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAP EST: Septic Tank Q Sewer Lines it Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property Line_ Private Domestic Well Public Domestic Well <br /> 1 INTENDED USE -TYPE OF WELL rr <br /> ❑ 15peSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ <br /> 5315OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing C' <br /> 11IRRIGA-F(ON `� �,• ❑ G PACK Depth of Grout Seal d <br /> 11CATHOI]!C PROTECTION' ,ROTARY Type of Grout ti{ <br /> IJ DISPOSAL f ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> 1 GEOPHYSICAL <br /> PUMP INS <br /> TALLATION: Contractor '' �•"°""t € '" "�"` <br /> H.P.` -n <br /> ype o Pump <br /> PUMP REPLACEMENT, _0 State Work Done <br /> PUMP REPAIR: t -❑ State Work Dona; '' <br /> DESTRUCTION•OF`tfIfELL: Well Diameter � . Approximate Depth <br /> K Describe Material and Procedure <br /> r �. <br /> I hereby cerEify t a ave pre =red th '4 plication and.that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules_and,_regul.atio�ns of•the San, oa ui -'Local..Health District. <br /> Home o'o ner'or licensed agent's signature certifies the following."I certify that in the performance of the work for whicl-.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 /> s <br /> ohllacting signature certifies the following: <br /> Carftractor's}hirrig or sub-cI certify that in the performance of the work for which this <br /> permit is issped, I shall employ persons subject td workman s coFnpensatibn laws of California." j <br /> *I will call 1 E a Grp pectioet-prior-to-grouting-and4h final inspectidn. <br /> ^ Date: "dwy <br /> Signed X + • rTitfe: _ <br /> 1. f •� (-DrawPlot n on Reverse Side) <br /> s <br /> t r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - F ° ® Date <br /> Additional Comrrients:� <br /> II Grout Inspection -� Pl e ill Final Inspection <br /> Inspection B)p Date - - Inspection- <br /> Date- <br /> I e <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ Juky 1 &Received By July 31 <br /> } REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE C CKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> { OUNT <br /> FEEf VV <br /> LESS �`U✓ <br /> PRORATION <br /> r PLUS <br /> r PENALTY <br /> fay-T'EWa EiC1-fY �. a +if/ � L Y <br /> OTHER <br /> "` c� , <br /> OTHER v — - jyh Z J <br /> 41 <br /> 36, <br /> Received by Date Receipt No.,- - - Permit No Issuance ate - Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />