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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ d <br /> FOR OFFICE li APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> + ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> r Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1 4 2A 1Ft�tft� City/Town `�U`t <br /> Owner's Name 2 f d � -C Phone <br /> Address a Q 0__ _ City ~� <br /> I Contractor's Name �Q License# 7>­I)` <br /> usiness Phone "13 '3d0 7— � <br /> Contractor's Address rl Emergency Phone iii jL.f*2-y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L-"'. No <br /> TYPE OF WORK {CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® <br /> REPLACEMENT❑ s <br /> DISTANCE TO NEAREST: Septic Tank 5 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 /> I ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing `~ � <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur Ce Seal Installed By: (� <br /> PUMP INSTALLATION: Contractor ToZ, 'll <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 19 State Work Done V1 <br /> PUMP REPAIR: ❑ 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 ru,les_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 forwhich this permit s 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 w' caI n for to grou <br /> ll to a Groutlspe ting and a final inspect'an. 1� <br /> Signed X Title: V�'�' .`"""� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By T, Date d <br /> Additional Comments: t <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> i <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 $ <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS /' GG <br /> PRORATION U21 <br /> U <br /> '-PLUS <br /> PENALTY ✓t'L,//Iiz <br /> OTHER <br /> OTHER �+ <br /> Received by, Date-k 4 --Receipt No. Permit No. Issi Date Mailed Delivered r I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES '.1601 E.HAZELTON AVE.,P.O.Box 2009: STOCKTON,CA445261' 7" <br />