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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) <br /> 0�0' PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WAFER 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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 6 ^ City/Town �M/��'ca >V <br /> Owner's NameTyr' W[C+✓ _ J "! r Rhone <br /> Address 1 F-7 t el �^ City MC & <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No \ <br /> TYPE OF WORK(CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 I Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑1 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor to LIPj" <br /> I Type of Pump 6t'. U H.P. .2 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑i SState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater' I 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 <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 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." a <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 subject to workman's compensation laws of California." <br /> Iwill II fora Grout Inspection prior to grouting and a final inspection. q <br /> Signed X ! Title: Date: I 7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> Application Accepted By 2�d Date r� _ <br /> Additional Comments: r ' <br /> Phase 11 Grout Inspection Pha e I Final I pection <br /> Inspection By Date T Inspection By / bate <br /> .+�- <br /> 7- -77 <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> i AMOUNT <br /> FEE i le <br /> LESS <br /> PRORATION �} <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �] 1 li-i I <br /> Received by Date Receipt No. Permit No, Issuafnce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 5201 <br />