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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> M <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WEf_1. . <br /> ENV ONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) /1 WATER QUALITY <br /> �' � <br /> Application is hereby made to the San Joaquin Local HeaiiFi strict fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with n Jo quip County Ordinal e No. 1862 ind-the rules nd regulations of the San Joa ig Local Health District. <br /> Exact Site AddressCity/TownC <br /> Owner's Name Phone <br /> Address City <br /> Contractor's !Name License# O Business Phone ����� 7 9 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q5 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION u DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT©.__0THE_R 0 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT 11pp t <br /> l DISTANCE TO NEAREST: Septic Tank C Oho i Sewer Lines Pit Privy <br /> ' t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line `z Private Domestic Well Public Domestic Well f <br /> INTENDED USE\. TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation, — <br /> C� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILL' �r ED Dia. of Well Casing — <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing { <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout OV- <br /> l ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Install d By: P <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pumpr <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done { <br /> PUMP REPAIR: <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Iz <br /> Describe Material and Procedure <br /> ) <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,10. <br /> Homeowner or licensed agent's signature.certifies the following:"I certify that in the performance otthe 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 foriwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I will call'for a Grout Inspection-prior to grouting and a final inspection. <br /> Signed X CI7 A r Title: 1 ����J �O Q _ Date: <br />` (Draw Plot Plan on Reverse Side) <br /> IFOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By L 5� <br /> 4 _ <br /> Additional Comments: f � .. <br /> A' <br /> a e II Grout Inspection as II Final Ins Pee tlo <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 AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> I DATE DATE REMITTED AMOUNT <br /> 4-- <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS <br /> PENALTY i <br /> y ! i <br /> OTHER _ - <br /> li <br /> OTHER <br /> Received by:-c. Date Receipt No, ' Permit No. Issuan4e Date MaiSed Delivered " ,�- <br /> `- ..��.......,, ­i..Tn. ouu1QnMU9MTA1 HFAr TN VFRUiT1gFRVICES 1601 E.NAZELTON AVE:.P.O.Box 2009 - STOCKTON,CA 95201 <br />