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nNF+n.mw � rr uuc rv.raamu rricn ouvnnicu raiNcn� a.u }nccw. vc .�uc �ayn enc nRNna:auan. <br /> FOR OFFICE USE: APPLICATION <br /> (--Nor;tor Non-Transferable,Revocable, Suspendable)n <br /> .ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with g nn.1-aquin County 00f dinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. , 1, <br /> Exact Site Address-..� a .,$4r 'y j - - . City/Town <br /> ILL Phone _ <br /> Nam � — <br /> Owner's e �� �i�/ <br /> t� Cit 1 <br /> Address Y s- <br /> n e#: e.' � Business Phone k7 <br /> ice s <br /> Contractor's Name � <br /> Contractor's Address 17t ►c / l�J Emergency Phone _'eX -40 N ti) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia:of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge 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 _ H.P. <br /> PUMP REPLACEMENT: 19 State Work Donela <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 We San Joaquin Local Health District. <br /> Homeowner 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 /> 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 If for a Grout Inspection.prior to grouting and a final inspection.` <br /> Signed X Title: _ -t'� of Date: <br /> AV� (Dr Plot Plan o Reverse Side) <br /> If 70 Ag& <br /> FO DEPARTMENT USE ONLY /Q <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> -Phase 11 Grout Inspection a 111 Fi Ipsection _ <br /> Date Inspection B Date - <br /> Inspection By P <br /> �7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Heceivetl By Januar ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> � DATE DATE REMITTED 1�fy AMOUNT <br /> FEE 7/ <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> I , <br /> OTHER <br /> i <br /> q OTHER ! <br /> Received'by Date = Receipt No. Permit No. iissulince Date Mailed Deli d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.-BOK 2009 STOCKTON,CA 95201 <br />