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ApplicationsWill BeProcessedWhen Submitted ProperlyCompleted. Be SureToSignTheApplication. <br /> FOR OFFICE U _/� APPLICATION <br /> e_0 m �t (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 in compliance with San Joaquin ounty Ordinanc No. 1 62 and the r /es and regulations of the San Joaquin Local Health District. <br /> Exact Site Address e. h Ute S p Q 0// City/Town <br /> Owner's Name f-4* _- Phone <br /> Address4 0 74 City r t. <br /> Contractor's Name 7Ls�r kl r License# 1W " Business Phone <br /> Contractor's Address d a C AJ Q Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit II HD? Yes Ok No { <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �/ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <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 pia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 14 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 0 DISPOSAL ❑ OTHER Other Information .< <br /> ❑ GEOPHYSICAL Surface Seal Inst By: <br /> PUMP INSTALLATION: Contractor �"` <br /> Type of Pump li vb IeA H.P. /0 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done ' aR R bJ F_1_0 44/ "Da ✓ c U +:3' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure �m <br /> 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 Health District. f� <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 for which this <br /> permit is issued, I shall employ persons ssuub'ect to workman's compensation laws of California." <br /> I WPI call for a Grout Inspe ti p r 5 gr ing and a final inspection. <br /> 1 <br /> Signed X ilie: .ii✓^.rysl¢ Date: <br /> (Draw Plo Ian on Re erse Side) <br /> FOR DEP RTMENT SE ONLY <br /> PHASE <br /> Application Accepted By �`r" Date <br /> Additional Comments: ( / 41 <br /> Phase Grout Inspection ha 111 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAT DATE REMITTED AMOUNT DVE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> 3 � r a <br /> Received by Date Receipt No. ermit No, ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKi yv'�A 95201 <br />