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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppllcatlon. <br /> FOR OFFICE USE: APPLICATION 4v7-- -2-� <br /> (For Non-Transferable,Revocable, Suspendable) / PUMP&WELL <br /> j ENVIRONMENTAL HEALTH PERMIT <br /> WATER,QUALITY,,, ,,� �,.. <br /> (COMPLETE IN TRIPLICATE) I� IV- I11 ' ' -- v.' lication is <br /> t~ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or.install the work herein described.This app <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 o� ", o City/Town <br /> Owner's Name fl/C 9�- a :ate Phone I <br /> E C� 'baa , . <br /> Address City <br /> } <br /> Contractor's Name — License Business Phone- S� <br /> r 1 <br /> Contractor's Address r� �� —� Emergency Phbne' <br /> Is Certificate of Workman's Compeisation Insurance on File With SJLHD? Yes No r GJ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ _RECONDITION❑� DESTRUCTIO,NNEI <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C1 - OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ ' <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 Q� <br /> INTENDED USE P TYPE OF WELL O <br /> ❑, IN,USTRIAL C3CABLE TOOL Dia. o1 Well Excavation I <br /> Ifd�DOMESTIC/PRIVATE i ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL c Surface Seal Installed By: . <br /> PUMP INSTALLATION: Contractor <br /> f Pum , <br /> Type p H.P.o � <br /> I <br /> PUMP REPLACEMENT:- 11 State Work DonI <br /> PUMP REPAIR: 11 state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ais Describe Material and Procedure <br /> I hereby certify that I ti ave 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 /> Horne owner or licensed agent's signature certifies the following."I certify that in the performance of the work for which th is 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will callr rout ns ction prior to grouting and a final inspectlon. <br /> r <br /> Signed X <br /> Dlt _ Title: gate: —� T <br /> 1. ill (Draw Plot Plan on Reverse Side) <br /> ! FORDEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: I <br /> Phase II Grout Inspection Phase 114 Final Inspection <br /> Inspection Date Inspection By Date <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH r ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ' <br /> BASE i� EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS I� <br /> PRORATION I, <br /> PLUS i ~ <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> I b - <br /> — Date a Receipt No Permit No. �- Iss nce Dat - Mailed Delivered f <br /> a Received by 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />