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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EFORFICE APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ( PIMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �Zgop t r�P�✓� /�WATER QUALITY ,..,, w,,r 3 p4 f3 <br /> (COMPLETE IN TRIPLICATE) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inst ICthe work herein described.This application is <br /> made in compliance ,- San Joaquin County Ordinance No. 1862 and the.rules and regulations of the San Jopquin Local Health District. r <br /> Exact Site Address r �Q� 1 j��ity/Town I NO�CN <br /> Phone k. <br /> Owner's Name &)MJ <br /> Address r', ,vim` N(f✓ 'Gd City - <br /> Contractor's Name t7 r F License#3 f3/Y Business Phone' <br /> Contractor's Address i vg C<A0 i LtdJ 'Emergency Phone ham` <br /> Is Certificate of Workman's Compensation Insurance on File WithSJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRO <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other N <br /> Property Line Private Domestic Well Public Domestic Well N <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL nti t{ Dia. of"Well Excavation <br /> © INDUSTRIAL led, <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing m <br /> 0MESTIC/PUBLIC [],,DRIVEN Gauge of Casing <br /> a s <br /> ❑IRRIGATION AVEL PACK Depth-of Grout Seal' <br /> ❑ CATHODIC PROTECTION V ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ti <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: . O State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> 5 <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 /> 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 /> r:. <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhic t Is t <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. - ; <br /> /� �� �,-/l�fy,. Title: Date: <br /> Signed X s (Draw Plot Plan on ReversT a Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 d3 Date i <br /> Application Accepted B I <br /> Additional Comments: ` <br /> • Phase 11 Grout Inspection a final Inspection ,Q <br /> Inspection By " Date Inspection y <br /> !/ Date NO U <br /> Fee Is Due: ❑ ANNUALLY '[I PER UNIT El PER SITE El EACH - EDJanuary 1 ceive8 By January 31 July 1 &ReceivedREMBy IT 31 - <br /> BASE #EXPLANATION - BILLING - REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ? <br /> PLUS e <br /> PENALTY <br /> OTHER <br /> A •Y <br /> Y � <br /> OTHER <br /> Received by <br /> D to Receipt No. Permit No. Issua a ate Mailed Delivered <br /> --N. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Box 2009 S14JCKTON,CA 95241 <br />