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" Applications Will Be Processed When Submitted Properly.'Completed. Be Sure To Sign The Application. <br /> FOR OFFiCE.USE: APPLICATION '} <br /> r ;W (6 iwtooC//A (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> J <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> i <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rulea and regulations of the San Joaquin Local Health District. t <br /> Exact Site Addressyei.lr � City/Town <br /> Owner's NameF # Phone <br /> Address City— <br /> Contractor's <br /> ity Contractor's Name R Business Phone 2-—..-7e <br /> 7� <br /> Contractor's Address irkair Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJHD? Yes - No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION LJ DESTRUCTkQN_� <br /> WELL CHLORINATION C1WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLREPAIR 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t1 i <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 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal `f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Space Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump G H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 64 State Work Done co— # o- r__d, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth $ <br /> Describe Material and Procedure <br /> r <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 /> 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 forwhich this <br /> permit is issued, I shall employ per subject-to workman's compensation laws of California." <br /> I will all for a Grout Inspection prio g7utinI nd a final inspection. <br /> Signed X tle: �;r'>,� _ Date: ek <br /> (Draw Plot an on Reverse Side) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByDate <br /> Additions! Comments: <br /> Phase 11 Grout Inspection Phas I Mal Inspection <br /> Inspection By Date Inspection By Date <br /> a <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Lks <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br />+ OTHER <br /> Pat zlon . <br /> ReCeived by Date Receipt No. Permit No ss ane Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 EHAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />