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S .. <br /> • - <br /> Applications Will Be Processed When SubmittedProperly <br /> N <br /> i. <br /> FOi?.OF . . _. : (For Non-Transferable, Revacabie,Suspendable) PUMP&WELL <br /> 0 <br />� ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMptETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local He�aCehlDost1862 a dpermit <br /> the rules and regulattiiioons oft he S n Joaquin all thework in do scHee�strict, <br /> made in compliance with-San Joaquin County Ordina City/Town <br /> Exact Site Address a Phone <br /> Owner's Name _ City <br /> 6 - 74 74 <br /> Address License# X43"'?_ Business Prione <br /> �4 Contractor's Name Emergency Phone <br /> f Contractor's Address ? Yes No <br /> i is Certificate of Workman's Compensation Insurance on File WithtSJLHDSTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 C] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER C] PUMP 1NSTALLATION 13 PUMP REPAIR® <br /> REPLACEMENT El Sewer Lines ; Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> ` Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> t - Dia. of Well Excavation <br /> 11 ❑ CABLE TOOL INDUSTRIAL 1:1 DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PRIVATE ❑ RVEN Gauge of Casing <br /> 13DI <br /> DOMESTIC/PUBLIC ❑_ RVEL PACK Depth of Grout Seal <br /> IRRIGATION ❑ ROTARY Type of Grout V\ <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P. <br /> Type of Pump r <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done. <br /> PUMP REPAIR: <br /> state work Done Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe•Material and Procedure <br /> IIlcatior+ th <br /> and that e work will be done in accordance with San Joaquin County r <br /> I hereby certify that 1 have prepared this app 1 <br /> j ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the 1ollowir "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 /> ure certifies the following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signat <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California-" fl <br /> 1 w'I call for a Grout Inspec io rio to g and final inspection. <br /> ltle: = Date: <br /> Signed [ - (Draw Plo Ian on Reverse Side) <br /> OR PARTM T USE ONLY <br /> 1' <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phase Ili Final inspection <br /> Y Phase N Grout Inspection Date <br /> Date Inspection By <br /> Inspection By <br /> PER UNIT lB4T <br /> 'PER SE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee 16 Due: ❑ ANNUALLY ❑ REMIT <br /> l - BILLING REMITTANCE . S . AMOUNT DUE CHECKED <br /> BASE EXPLANATION DAT DATE - REMITTED AMOUNT <br /> 1 <br /> U <br /> FEE o -� <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY ![ <br /> OTHER I <br /> OTHER k <br /> ab <br /> Received by Date Receipt No. Permit No." issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2408 STOCKTON,CA 9520 <br />