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•^ �` - Applications Will Be ProcessedWhenSubmitted ProperlyGomplerea. leve sure Iosign ineAppira:atwn <br /> FOR OFFICE USE: APPLICATION pyo j U <br /> (For Non-Transferable, Revocable, Suspendable) f <br /> � PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN 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 with San oaquinount Ordinance No 1862 nd the ul and regulations of the San aquin Local Health District. <br /> Exact Site Address D D Al,y City/Town f <br /> Owner's Name Phone OF —/ — <br /> Address City <br /> Contractor's Name License#3 Business Phone <br /> UZeContractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Ins rance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <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,TOO_L Dia. of,Well Excavation <br /> ❑ DRILLED ng Dia. of Well CasiY <br /> DO(v1ESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout 1 C <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Su ap Seal Installed By: <br /> PUMP INSTALLATION: Contractor ) ` <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: / 11State Work Done t <br /> DESTRUCTION OF WELL:/ q/i� �i-Well Diameter Approximate Depth <br /> L Descri Mate i�nd cedure �U <br /> _ 0— v $Gl cs <br /> ereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ( J,�rdinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> q" �_1'� Rome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> D fl_ 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 call for a Grout Inspec 'on prior to grouting and a final inspection. <br /> Signed X A ` Title: ✓{ t Date: <br /> (Draw Plot Plan on Reverse Side) <br /> ✓" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE INa�Q(V� A. <br /> Application Accepted B 1�N + Date <br /> * t <br /> Additional Comments: :.� <br /> Phase II Grout Inspection' Ph a Final pection <br /> Inspection By51te Inspection 13y Data I/26/r4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 4 &Received By JanuaK- ❑ July 1 &Received By July 31 <br /> e REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED c AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7r Bo qo LIL4 a �7! 717852 <br /> Received by Date Receipt No Permit No. ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />