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Applications Will.Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL 4 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> a t [ f [ a <br /> ATER QUALITY <br /> 071 <br /> Application is herebymadetotz6i`quinLocalHealthDistrictapermittoconstructand/or _ 7 3 t7r3 Z <br /> install the work herein described.This appli'cation is 1 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules Jand regulations of the San Joaquin Local Health District. <br /> Exact Site Address �� /� /IV�.� ," FIlf�//S� City/Town <br /> Owne'r's Name r Phone., <br /> Address City ` A <br /> Contractor's Name ti,,: C' ,'; License# ]-11�03/C) Business Phone" v © �¢f ' <br /> AJ <br /> Contractor's Address <br /> Emergency.Phone <br /> Is Certificate'o f Workman's Compensation surance on File With SJLHD? Yes No <br /> TYPE OF WORK (CI IECICJ NEW WELL- --- DEr0EN ❑ RECONDITION❑�"_DESTRUCTION❑ ` <br /> WELL CHLORINATION ❑% WELL'ABAONMENT 1:11:1PUMP OTHER PUMP INSTALLATION❑ REPAIR❑ <br /> ❑"_".."'_,,.-- <br /> REPLACEMENT _. � <br /> ND,.�. <br /> DISTANCE TO NEAREST: Septic Tank CJS 36ver Lines _30—"ll Pit Privy <br /> 0Jiff-Flt, -4AOVL QTY Sewage Disposal Field Cess ool/Seepage Pit ..___? Ot er ��'' <br /> 4 ! f r <br /> r Property Line Private Domestic Well Public'Domestic Well <br /> INTENDED USE TYPE OF WELD i f / <br /> ❑ INDUSTRIAL ❑ CABLEFOOL /r Dia. of Well Excavation cllo K <br /> ❑ DOMESTIC/PRIVATE '❑ DRILLED Dia. of Well Casing <br /> $-DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �t1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal , <br /> ❑ CATHODIC PROTECTION ROTARY �" Type of Grout <br /> ❑ DISPOSAL• ❑'OTHER • Other Information "" ` " - t►�3 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1 " <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r <br /> -.PUMP REPLACEMENT: EI-State Work D'oneL` <br /> !jPUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ,Describe Material and Procedure.-- 1 <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 Healthi District. `*( <br /> Homeowner or licensed agent's signature certlfles-the'followif.•rd-erfify'thRt in the performance of the work forwhich 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:1 certify that-in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi I r a rout nspe I -r r to grouting and a final InspectioAn.� <br /> Signed X Title: <br /> E-'+t. '� Date: l <br /> (Draw Plot Plan on Reverse Side) A <br /> FOR DEPARTMENTUSE ONLY �� + <br /> PHASE I GUiGa".L �OR!!1 A7lllOfs2�UTEgrJ I 40AJ <br /> Application Accepted ) <br /> Date <br /> Additional Comment <br /> Kz <br /> Phase II Grout Inspection 788y <br /> III Final nspection ' <br /> Inspection By Date Inspection By Date <br /> Fee Is Due:.1.1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEI <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuanc6 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 '.5 <br />