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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION i <br /> (For Non-Transferable, !-Wcable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> l <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.'This application is <br /> made in compliance with San-Joaquin County 0 d'narlce 62 and the rules and regulations of the San Jo _ui octal ealth District. <br /> t <br /> Exact Site Address <br /> City/Town sr <br /> Owner's Name ter .✓ Phone r-� <br /> Address 49 <br /> ,"! City- <br /> Contractor's Name /- License#A&AM _ Business Phone a ` <br /> Contractor's Address r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLER"DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> 'WELL CHLORINATION ❑ WELL ABANDONMENT ❑ ._ OTHER ❑ PUMP INSTALLATION 0-' PUMP REPAIR <br /> REPLACEMENT❑ // <br /> DISTANCE TO NEAREST: Septic Tank Are, f Sewer Lines lure ` Pit Privy i/11 <br /> Sewage Disposal Field elo* Cesspool/Seepage Pit Other s <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �s k <br /> ❑ IN USTRIAL ❑ CABLE TOOL Dia. of Well Excavation /4T <br /> L# DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 4° , <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -ye--,6, / <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .ate N <br /> ❑ CATHODIC PROTECTION R OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contractor A > { <br /> Type of Pumper H.P. —� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure FJ <br /> 1 <br /> r <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:A 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 /> i <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 f r a Grout Ins ction rior to grouting and a final inspection, r <br /> Signed X Title: —1�. ..- - ,/ Date: /. <br /> (Draw Plot Plan on Reverse Side) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepf6d By_ �• Date <br /> u <br /> Additional .%mments: <br /> i v� a II Grout pection Phase III I spection <br /> Inspection By h ate f Inspection By Date - <br /> VFee Is Due: ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT i <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE rho O <br /> LESS <br /> PRORATION Y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> CIT 3�L 71 �Ul�!/(� �-/,1�) 425!­_ 7C` . <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Denver�U <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -- -,1601 E.HAZEt_TON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />