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i° tions Will Be Processed When'Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> � / <br /> (For Non-Transterahe, Revocable, Suspendable) ' <br /> PUMP &WELL <br /> _ ENVIRONMENTAL HEALTH PERMIT ° <br /> r �� s- UAB TY l g3-270 r Oq r. <br /> (COMPLETE IN TRIPLICATE) ( ,� � t, <br /> AppiicationisherebymadetotheSanJoaqumLocalHealthb rlctforapTani oconstructand/or install the work herein described.This application is <br /> ade in compliance with San Joaquin County Ordin No 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address y <br /> S� - `�[ �, Or' Q ve l roolp � City/Town 'r X & a <br /> Owner's Name Phone <br /> Address City07 <br /> Contractor's Name License# Business Phone �' tt <br /> Contractor's Address Emergency Phone y <br /> Is Certificate of Workman's Compensation Insurance on f=ile With.SJLHD? Yes No C7 <br /> TYPE OF WORK (CHECK): NEW WELL[3 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI <br /> REPLACEMENT❑ -0 <br /> DISTANCE TO NEAREST: Septic Tank 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ,} <br /> 1:1 DISPOSAL 11 OTHER <br /> Other Information ' <br /> 13 GEOPHYSICAL Surface S 1 Installed By: <br /> PUMP INSTALLATION: Contractor / pCj <br /> Type of Pump A H.P. S <br /> h PUMP REPLACEMENT: <br /> 1:1 State Work Done y <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l 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 /> I 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 will call for a Grout Inspection ho o out and a final inspection. <br /> Signed X itle: e z Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FORD PART NT USE ONLY <br /> t PHASE i <br /> Application Accepted Bye " Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha I final Inspection /L <br /> r <br /> ' Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ,❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKS <br /> DATE DATE REMITTEb t AMID <br /> % <br /> FEE <br /> # LESS _J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> s <br /> OTHER <br /> I Received by Date Receipt No Permit No Iss ante Date Maiied Delivered <br /> +� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 <br />