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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION f <br /> T (For Non-Transferable, Revocable, Suspendable) <br /> - RUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY R . <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance/No. 1862 and the rules and regulations of the San JoaquinCocal Health District. j <br /> Exact Site Address�C C? [fit 144 a cA-.--��af� City/Town c �} <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name VAA 01054,04, icense# � Business Phone _ 3 <br /> Contractor's Address mergency Phone �' 9 1 <br /> L&nn a on File With SJLHD } <br /> Is Certificate of Workman's Compensation Insura ? Yes �' No rn ! <br /> TYPE OF WORK (CHECK). NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> p� t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT M-- 1 L <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �� � Pit Privy <br /> Sewage Disposal Field •Ld I Cesspool/Seepage Pit Other <br /> Property Line rZ Private Domestic Weil Public Domestic Well I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing <br /> 1 <br /> „�,DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor VM1 0 a— <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: -State Work Done1pVull - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 for which 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 /> 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 Gr Inspection prior to grouting and a final inspectfo . <br /> Signed X Title: Date: <br /> (prow Piot Plan 7 Ill <br /> an Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 r M_� - �` <br /> Application Accepted By elf �L" r Date f _,1�2-—E <br /> Additional Comments: <br /> Phase II Grout Inspection Ill final Inspection �7 !!F <br /> Inspection By Date inspection By Date `D <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 Y <br /> IvqFEE 4 i <br /> LESS e <br /> PRORATION <br /> PLUS <br /> PENALTY . <br /> i <br /> OTHER i <br /> 1 � <br /> OTHER <br /> Received by Date _ Receipt No. - Permit Nb: Issqance Dat C1 Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />