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i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> — <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL 1 <br /> (COMPLETE IN TRIPLICATE) 4j!-3-:5Z-4 WATER QUALITY <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 /> made in compliance wit Sa Joaqu n County Ordinanc ,1No. 18622 and the r s and regulations of the San Joaquin Lpcal Health District. <br /> Exact Site Address u ` own <br /> ��/� <br /> Owner's Name t�,/&Z Phone �"` <br /> CXJ <br /> Address City- <br /> Contractor's Name r License# f1S'" Z Business Phone_ -�!l 0 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS. PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank / Sewer Lines Sib l • Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other W <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation i. <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal j <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL E] OTHER Other Information - <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ^' <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I. <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t will call for a Gr inspection prior to grouting and a final inspection. <br /> Signed X Title:, Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE'I <br /> Application Accepted By - Y-e�` - Date LP <br /> Additional Comments: <br /> { Phase 11 Grout Inspection P e i Final Inspection <br /> Inspection By NIA Date Inspection By — 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 /> BASE EXPLANATION BILLING REM}TTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> fj AMOUNT <br /> r EEE 2!1 O G P� <br /> rTM <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ���$� � <br /> Received by Date Receipt No. Permit No. Issuance ate Maiied Delivered <br /> o- APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />