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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign �p{itJ� WJ LS V Z I I <br /> a <br /> FOR OFFICE USE: APPLICATION ■�gg �� � <br /> (For Non-Transferable, Revocable, Suspendable) PUMP L <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY h� iy�a FYI LOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work here i est&' d.'1�tls� 1i�sation is <br /> made in compliance with San Joaquin Co ty Or finance No. 1862 and the rules and regulations of the San Joaquin Lo al Health District. <br /> Exact Site Address f�—y/ + City/Town EJB , <br /> Owner's Name Phone r L� <br /> Address y City <br /> Contractor's Name License#9kle Business Phone <br /> Contractor's Address 111A22,NEEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL 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 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> t1DOMESTIC/PRIVATE ❑ DRILLED Dia. 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 S rface Seal Installed By: —� <br /> PUMP INSTALLATION: Contractor �-cov f <br /> Type of Pumper H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done /f <br /> PUMP REPAIR: IN 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 <br /> ordinances. state laws, and rules and regulations of the San Joaquin Local Health District. <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Lit Inspection prior to grouting and a final inspeen.y� <br /> Signed / .?ty.[S�y� Title: pe, <br /> Date: 1 / <br /> y (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted 13y 1� Date�����~ <br /> Additional Comments: <br /> Phase 11 Grout Inspection P ase III Final Inspection <br /> Inspection By Date inspection By Date 17 <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 5 5 O <br /> LESS <br /> PRORATION <br /> PLUS My <br /> L,�.( <br /> t _ <br /> OTHER _ � - <br /> OTHER 7 �1 41- (/W <br /> � <br /> D o� 1. f( G�rVtrJl -JY+ij wtP.L— <br /> Received by Date t Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />