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Appli71�, <br /> ions Will Be Processed When Submitted ProperlyCompleted.l3eSure t,osig neAppicatlull. / <br /> EOR OFF CE USE: APPLICATION" b , /'Y/ <br /> [ (For Non-Transferable, Revocable, Suspendable). pUMp&WELL <br /> j ENVIRONMENTAL HEALTH PERMIT <br /> r � <br /> -.(COMPLETE.INWATER QUALITY-TRIPLICATE), I - <br /> tAppfication is hereby madetothe San Joaquin Local Health Di stri6t for a permit to construct and/or instal I the work herein described.This application is k <br /> made incompliance with San Joaquin Count: rdinance No. 1$62 and the rules and regulations of the San JOB iJin Local Health District. . <br /> Exact Site Address O City/Town � l U <br /> Owner's Name h { �� �Q Phone r <br /> Address,- City <br /> L y�r.a License# Business Phone I <br /> Contractor's Name- <br /> Contractor's Address J .`� Emergency Phone <br /> Is Cerlificate of Workman's Compensation Insurance on File With SJLHD? Yes o <br /> TYPE OF.WORK (CHECK): NEW ELL RECONDITION❑ ESTRUCTIO <br /> WELL CHLORINATION ❑ ELL AB NDONMENTDI OTHER ❑ PUMP INSTALL PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ , q Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Welj>l �_ Public Domestic Well <br /> INTENDED USES TYPE OF WELL <br /> ❑ INDUSTRIAL _ ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ELIC ❑ DRIVEN ,,, .,-- » rGauge of Casing - _ - <br /> IRRIGA "— ❑ 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 <br /> _ <br /> Type of Pump H.P. vri <br /> PUMP REPLACEMENT: ❑ State Work Done • <br /> PUMP REPAIR: ❑ State Work Don <br /> DESTRUCTION OF WELL- Well Diameter A proximate Depth <br /> Describe Material and rocedure- 0� <br /> I hereby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin County <br /> ordinancesstate laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certity that in the performance of the work for which this permit <br /> ompensation laws of California." � <br /> is issued,_I shall not employ any person-in sucFi manner as to become subject to workman's c . <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, 1 shall employ persons subject to-workman's compensation laws of California." <br /> III call-for a Grou Ins tion prior to 9 ouan It al ins ction. ' .rM4q4 l�] f <br /> Sign d X Date: L , <br /> rraw Pio a on Reverse Side) <br /> i <br /> y FO DEPARTMENT USE'ONLY ., <br /> PHASE I ] <br /> Application Accepted By Date -.r <br /> Additional-Comments: <br /> �f a e II Grout Inspection Phase ill Final Inspection w, "$ <br /> Inspection By / Date` - C / v Inspection By dt —'Date <br /> Fee Is Due: ❑ ANNUALLY .'[3 <br /> PER UNIT- El PER SITE .❑ EACH ❑ Jly 31 <br /> January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy Ju <br /> MIT <br /> BILLING REMITTANCE- <br /> CHECKED <br /> BASE EXPLANATION AMOUNT DUE <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS tl � � <br /> PRORATION LIS <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> ! S <br /> Re eived by - Date -Receipt No. Permit No Issuance Date Mailed Delivered <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />