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Applications Will Be Processed When Submitted Properly Completed.Be Sure To SignMpplication. <br /> ,FOR OFFICE USE: APPLICATION IAN 1 1981` <br /> (For Non-Transterable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JHEA� N�lSTRi CAL <br /> CT <br /> (COMPLETE—IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health district fora permitto 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_!&,3 S, y'n City/Town <br /> Owner's Name O V z Phone &251e ? <br /> Address ,•s City e'v —1 <br /> t� 2 •� License# D� Business Phone <br /> Contractor's Name J <br /> Contractor's Address �r�=/��" •_ Emergency�Phone S'��� �"` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No A <br /> TYPE OF WORK'(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT® i1, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy U <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well ' <br /> INTENDED USE i TYPE OF WELL <br /> ❑ INDUSTRIAL , ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN YGauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump :1 H.P. s <br /> PUMP REPLACEMENT: ® State Work Done Ic1�.?►71t.�2 T- ( 1t �7/J�li `�� pr, <br /> ❑ State Work Done I vt <br /> PUMP REPAIR: x <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth l!3 <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 /> f <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I will colAor a Grout Insp ion prior to grouting and a final in:everse <br /> pe n. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Side) <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> PHASE I pZ1 O!� <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> hase 11 Grout Inspection has I Final Inspection <br /> Inspection By Date Inspection Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE ❑ EACH ❑ January 1 8Vmv.I'By <br /> January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE LA <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by to Receipt No- - Permit NO Issuance Date Mailed;- - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />