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A. <br /> J Appiications Will Be Processed When Submitted Properly Completed.BeSureTo51gnTnewppauv++. <br /> FOR OFFICE USE: i' APPLICATION <br /> E (For Non-Transferable, Revocable;Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ' S <br /> WATER QUALITY h....,iL ft 21:t" t" j.• r <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or.install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the`rules and regulations of the SanJoaquinLocal Health District. <br /> Exact"Site Address ` C� ) City/Town ' <br /> Phone <br /> Owner's Name <br /> &IlCity _ <br /> Address '+ " <br /> ` License#�- f.-Business Phone <br /> Contractor's Name ri,. r„'IX <br /> • _ - <br /> Contractor's Address Errt6rgency Phone No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK❑): -NEW W ABANDONMENT ❑DEEPEN ❑ REC OTH RO❑ ITIO�❑P iNSTALLAT ON N MP REPAIR❑ <br /> WELL CHLORINATIONWELL <br /> REPLACEMENT❑ ;' <br /> Sewer Lines Pit Privy ,-•— <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Sewage Disposal Feld Cesspool/Seepage Pit <br /> Property Line. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INQUSTRIAL iL� 11CABLE TOOL Dia. of Well Excavation <br /> 0-DOMESTIC/PRIVATE II 11DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC I� <br /> 13 DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ' ❑ IRRIGATION � ,i ' <br /> ❑ CATHODIC PROTECTION 11 13 ROTARY Type of Grout <br /> �! Other Information k <br /> i ❑ DISPOSAL � EI OTHER <br /> ' ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:r i; Contractor <br /> H.P. <br /> Type of Pu mp <br /> PUMP REPLACEMENT: �� ❑ State Work Done y. <br /> I I <br /> PUMP REPAIR: ❑ State Work Done iApproximate Depth <br /> DESTRUCTION OF WELL: I� WeII Diameter <br /> Describe Material and Procedure <br /> i f <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 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: ' certify that f 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 /> I will tali for. Grout Inspectio prior to grouting and a final inspection. I <br /> Signed X <br /> � � r .Title: 'v-,.e.� r Date: �� -��=t`c `--r�• <br /> I (Draw Plot Plan on Reverse Side) ` Ci <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date / /� - <br /> Application Accepted By - <br /> Additional Comments: <br /> f Phase II Grout Inspection se I F' al Inspection <br /> Inspection By <br /> Date- Inspection By Date <br /> d By <br /> ' Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑"EACH' ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveREMlTuly 31 <br /> 'L BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Iq <br /> FEE - <br /> LESS ll I j <br /> PRORATION c ' <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No.' ermit No.___-; Isjuamb Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES 7D: ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Bos 2049 STOCKTO.W CA 95204 <br />