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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLIC f-,p- �Z: <br /> (For Non-Transferable, R bl!S peG� e) I D <br /> PUMP&WELL <br /> ENVIRONMENTAL LT ERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY MEPP 26 1979 <br /> Application is hereby made to the San Joaquin Local Health District for a permit t6Cm tr tand/orinstalltheworkherein described,This application is <br /> made in compliance with San Joaquin CouJ}ty Ord nye No. 18 and t r les�pdgfuf�f r quin o I Health District. <br /> Exact Site Address �— __ t � � <br /> Owner's Name '�^�"` I j 9- 3 710 <br /> � Phone <br /> Address City <br /> Contractor's Name License#A,, Busin s.s Phone )J ; <br /> Contractor's Address - Emergency Phone .�� S t <br /> I <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ (� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <br /> REPLACEMENT❑ —4% <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 TOOL Dia. of Weil Excavation <br /> ❑ DOMESTIC/PRIVATE .-❑ DRILLED Dia. of Well Casing <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 E�yrface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 10 ®� <br /> Type of Pump , H.P. <br /> PUMP REPLACEMENT: C1State Work Done <br /> PUMP REPAIR:. R—State Work Done <br /> DESTRUCTION-OF'WELL: Approid-mate Depth ` <br /> Describe Material and Procedure i <br /> 4. <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work torwhich 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 11 for Grout in Cion priorto gro . g and a final ins ection. _ <br /> Signed X Title: Date: r� '. <br /> Draw Plot Plan on Rever Side) <br /> FO DEPART NT USE ONLY <br /> PHASE I o <br /> Application Accepted By Q� Date <br /> Additional Comments: <br /> Phase it Grout Inspection Ph I Final I pection <br /> Inspection By Date iV R Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITF ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT I <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> a <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r 1 <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1681 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />