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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. a <br /> FQ9 OFFICE USE: APPLICATION <br /> t (For Non-Transferable, Revocable,Suspendable) h <br /> 5 <br /> PUMP&WELL <br /> 1 ENVIRONMENTAL HEALTH PEAMIT <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforape.rmittoconstructand/or install theworkherein described. Ns application is <br /> made in compliance wrl h San Joaquin Co my Ordi.ance No. 18/6?and the rule an regulations of the Sa oaquin Local Health District. <br /> Exact Site Address City/Town ' <br /> E Owner's Name 42-" 1i .S[/4� e <br /> Phone © ! <br /> C ct/� 0 <br /> o ress <br /> Contractor';Name/r G� � ' icense# 0_01 Business Phone <br />' Contractor's Address -„z2_0_4W/Us -5_06d/ [?hone ou a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q>, <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTIO}N1❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION 1& PUMP REPAIR© <br /> REPLACEMENT❑ �y <br /> i r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 5�4 Pit Privy <br /> •-• Sewage Disposal Field��liw. i_n_e— Cesspool/Seepage Pit �d1]t� Other <br /> i Property Line/ vate Domestic Welham Public Domestic Well <br /> INTENDED USE iTYPE OF WELL <br /> i ❑ INDUSTRIAL CABLE TOOL :Dia:of Well Excavation <br /> 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ •DRIVEN -- - Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK 'r- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY., Type of Grout r +� <br /> I ❑ DISPOSAL ❑ OTHER Other Information <br /> t ❑ GEOPHYSICAL Surface Seal Installed By I`i Ile-!" 0 <br /> t PUMP INSTALLATION; Contractor ez G i` r <br /> Type of Pump A a 1""�md-`P W H.P. -P/7x-, f <br /> j PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j Describe Material and Procedure <br /> r 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 law§;and rules and r�V.. lations of the San Joaquin Local Health District. <br /> Home owner or licensed agept signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 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 wil all for a Grout Insp tlo prior grouting, d"a final inspection. <br /> kSigned X Title: � ��`� Date: <br /> ^ (Draw Plot Pian on Reverse Side) = <br /> -FOR DEPARTMENT-USE ONLY,' T <br /> R PHASE I +. .. A(>-w_-8a: <br /> Application Accepted By Dat <br /> Additional Comments: t <br /> P ase 11 rout Inspection Pha a tiI Final Inspection <br /> Insp�ctiori By b Date Inspection By — `� ..Dat <br />}{ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT r ❑ PER SITE ❑ EACH ❑ January 1 &Received.By January 31 a _ ^ ❑ July 1 &Received By July 31 <br /> p - BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATEy DATE REMITTED AMOUNT <br /> m <br /> I FEE <br /> LESS <br /> 3 PRORATION <br /> l PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER - .. <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95205 <br />