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Applications Will Be Processed When Submitted Properly CompII jBi,4u'Wfi�tjgn Ae 2t . <br /> FOR OFFICE USE: APPLICATION 1M <br /> ENVIRONMENTAL <br /> x (For Non-Transferable, Revocable, SuspendablgJ U_ 1 2 6 190 f <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) Sp S J i rvE WATER QUALITY SAN JOAQUIN <br /> HEAaJH D ��"RICT <br /> ApplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinsta t ework herein described.This application is <br /> made in compliance with San Joaquin Co t O dinance No.1862 an t e rule an regulations of the San Joaquin Local Health District. � <br /> Exact Site Address ��r � City/Town �Fr�L <br /> f <br /> Owner's Name 7-0 _ Phone <br /> Address City Z9 <br /> Contractor's Name License# u i ess Phone <br /> Contractor's Address G Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK): NEW WELL'❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ j <br /> J <br /> WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ! <br /> REPLACEMENT >I J ., <br /> DISTANCE TO NEAREST'` 'Septic Tan k""�"y '" '' 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 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL' Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC C7 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal Q' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor j <br /> ��Ty,�pee of Pump H.P. <br /> PUMP REPLACEMENT:. `L�;State Work Done L <br /> PUMP REPAIR: © State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> 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:"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 fallowing:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject work n's compensation laws Of California," <br /> will call r a Grout I pection 1 to gro Ing an final inspection. <br /> Signed X e6 file: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY t <br /> PHASEI <br /> Application Accepted By Date -136- M <br /> Additional Comments <br /> Ptose II Grout Inspection Phase 111 Final Inspection <br /> Inspection By pate Inspection By_ Date -7 /1'H <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece#W By January 31 ❑ July 1 &Received By July 31 - <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED � <br /> DATE DATE REMITTED AMOUNT F <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY , <br /> OTHER <br /> OTHER 41 m <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered h <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ... 1601 E.HAZELTON AVE.,P.O.Box 2009 —STOCKTON;CA 95201 ." .± <br />