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Applications Will Be Processed When Submitted Properly Completed. BffdefioSign The Applica%nflui <br /> FotroFF>U� usE: _ APPLICATION 1p <br /> APR Z pr� <br /> (Far Non-Transferable, Revocable,Suspendable) U <br /> . PUMP &WALL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT 2­03 0&0-02 ` <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made i._c m lia'ncE.*��th San Jo_a_quin Courant_ Ordi nce No. 1862 and the ru es and regulations of the San Joaquin Local Health District. <br /> ExactTiKddr�se��,~� IC City/Town <br /> Owner's Name t✓t9i1J f A.) �� Phone <br /> Address o 106 A/4: City <br /> Contractor's Name yob License 4_3s'��� Business Phone <br /> Contractor's Address „��%A! 5 r CA, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f!_ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ F <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 f <br /> INTENDED USE TYPE OF WELL <br /> ❑ 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 Depth of Grout Seal U <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor p . <br /> Type of Pump be-0 &WI V&Jn;A. %j ►” H.P. 7S� <br /> PUMP REPLACEMENT: ❑ State Work Done 4 <br /> PUMP REPAIR: ❑ State Work Done ..; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County �Il <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. P <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, l 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 /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> -T` <br /> Signed X 3-31-St <br /> Title: Date: � <br /> (Draw Plot Plan on Reverse SiA) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I ,�7/ 3 <br /> Application Accepted By `u" �/is Date <br /> Additional Comments: <br /> Phase II Grout Inspection P III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: El ANNUALLY ElPER UNVT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> 2 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I Date Receipt No Permit No Issuance Date Mailed Delivered x <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT./SERVE /T Q,?C1 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON. <br />