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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FGRE OFFICE USE: APPLICATION <br /> r (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application-Js <br /> made in compliance with Sa Joa uin County Ordinance No 1862 �}d the rules and regulations of the San o quin ocaI Health District. P <br /> Exact Site Address _u S s ! City/Town _, an QG14 <br /> Owner's Name my /� a`"l f Phone <br /> Address f . City� 10,11Q -y k <br /> Contractor's Name /` k0 ukz 4�00 icense#,a& <br /> Business Phone — <br /> Contractor's Address Emergency Phone _ <br /> ncz'l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION C, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION' PUMP REPAIR❑ <br /> REPLACEMENT❑ f21o1 / <br /> DISTANCE TO NEAREST: Septic Tank im Sewer Lines /04-/ Pit Privy <br /> Sewage Disposal ,iel�L Cesspool/Seepage Pit Other I <br /> Property Line D Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f <br /> DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing ell <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ?®& <br /> ❑ IRRIGATIONh❑e GRAVEL PACK Depth of Grout Seal �Q <br /> 13 CATHODIC PROTECTION ROTARY Type of Grout _ E <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: O_. E d! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Z <br /> - i <br /> PUMP REPLACEMENT: ❑ State Work Done s <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 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." 4 <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 wil1ligall tot a Grout In ection prior to outing and•a final inspection. l <br /> ki'� +�-� i&� Date:` <br /> Signed X Title: <br /> (Draw Plot Plan on Reverse Side) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date `o—All—W <br /> Additional Comments: <br /> PtVseill Grout Inspection1 _ a e III Final Inspectiony <br /> inspection By X—iGDate 1 z—� Inspection By� 1r^ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> FBASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT � <br /> FEE o ) t ; <br /> h i <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> i <br /> OTHER <br /> Received by bate Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br />