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a,,,,�•� - –.,Applications Will Be Processed When Submitted Properly Completed. Be <br /> FOR O FICE USE: APPLICATION <br /> .�� (For Non-Transferable, Revocable,Suspendable) - PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew ork herein described.This application is <br /> made in compliance with San Joaquin ounty Ordi n e No. 1W2 and the r}II and regu ti sof the �a oa in La a4th Distric . <br /> 1JLP-/" �— —1 <br /> �r i <br />' Exact Site Address 1f <br /> Phone <br /> Owner's Name 11 1111City of / p i <br /> Address <br /> License# Business I <br /> Contractor's Name 15 K5 2 Z/ i <br /> E- Contractor's Address Emergency Phone _ v�L— <br /> V No ! } <br /> Is Certificate of Workman's Compensation Insur nce on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION 13 DESTRUCTION { <br /> WELL CHLORINATION 13WELL ABANDONMENT 1:1OTHER 1:1PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Pit Privy ; <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Other <br /> . Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL J/ <br /> ❑,,/INDUSTRIAL. ❑ CABLE TOOL Dia. of Well Excavation "o I` <br /> s Lf+ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Y <br /> 11DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing G[� 1 <br /> 11 IRRIGATION <br /> UY"GRAVEL PACK Depth of Grout Seal ^ <br /> Type of Grout <br /> El CATHODIC PROTECTION Q/�OTARY YP _ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ! ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> y. Type of Pump <br /> (' PUMP REPLACEMENT: 0 State Work Done- - <br /> = PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I, ordinances, state flaws, 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 /> I permit is issued, 1 shall employ persons subject to workman's compensation laws of'California." _ <br /> I will all for a Grout Inspec n prior to grouting and a final inspection4Side) r <br /> g C_ <br /> Signed X <br /> Title:_ Dale: <br /> (Dr Plot Plan do Reverse <br /> I FOR DEPARTMENT USE ONLY 3 <br /> PHAE I Date J / <br /> Application Accepted By <br /> Additional Comments: <br /> t, 2Phase II Grout Inspection `6 Phase Ili Final Inspection <br /> L qate In I ectiton By Date <br /> Inspection By C <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EA' <br /> ❑ January 1 &Received By January 31 July 1 &Received EMIT 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> t PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> * OTHER _ <br /> � . 7 <br /> Recesved by Date <br /> Receipt No. Permit No, Issuance Date Mailed <br /> Deliv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />