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Appiwauonswits IlseProcessea wnen SuDmfttea ProperlyCompleted. BeSureTo SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> r.- <br /> (For Non-Transferable, Revocable, Suspendable) <br /> +� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE;_' J WATER QUALITY t)70 0 2-- <br /> Application <br /> Application is hereby made tothe an Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with S�yn Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local ealt District. <br /> Exact Site Address 'F , 0'T 6J City/Town <br /> Owner's Name �N Phone 4f xCJ �c7 <br /> Address fCity c9 <br /> Contractor's Name CLA l S License# Business Phone <br /> Contractor's Address ZO Emergency Phone <br /> Is Certificate of Workman's Compensation ns rance on Fl SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL�A DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t <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 - .13-CABLE TOOLt, �__Dia. of Well Excavation <br /> Jam...-� <br /> DOMESTIC/PRIVATE�__V.� _^y-C1,-.�bRILLED Dia. of Well Casing <br /> ❑,-,, <br /> DOM BLI <br /> EST)C/PUC__ ❑ DRIVEN Gauge of Casing �_L <br /> O-M-mMT10N ❑ GRAVEL PACK Depth of Grout Seal _ .__...C44 <br /> `�❑ CATHODIC PROTECTION ROTARY T - � <br /> ype of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: rN <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P, ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure F <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 forwhich this permit <br /> is issued, I shall not emplo y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or su con ratting signature certifies the following:"I certify that in the performance of the work for which this <br /> P ermit is i ued, I shal el ygr <br /> ns subject to wo an's compensation laws of California." <br /> I vuill cal a Grout nspe tion to groin" g n final inspection. <br /> Signed X -...► Title: -� Dat <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date /C� ���-�1` <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED , <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS f tel( <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> 10/)s -7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCi(TON, <br />