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r . <br /> Submitted Properly Completed.BeSure oSign <br /> Applications Will Be Processed When <br /> _:,r1FICE USE: <br /> - APPLICATION <br /> // A; <br /> x(For Non-Transferable, Revocable, Suspendable) PUMP&,WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY t <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for-apermit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance N^o�1862 and the rules and regulations of the'San Joaquin Local Hgaltly Distr' t <br /> City/Town —__o� t ��r �[ <br /> Exact Site Address ; <br /> Phone <br /> Owner's Name <br /> 2 <br /> Address C ' � City <br /> Ir <br /> Contractor's Name <br /> "� License# 5'A=?14Business Phone 6 ti -- 6 <br /> Contractor's Address W Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes �� <br /> No J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT ElOTHER 13PUMP INSTALLATION R PUMP REPAIR El -4) <br /> (�} <br /> REPLACEMENT❑ p. f <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field _ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> IN USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13CABLE 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / Q.r H.P. l <br /> PUMP REPLACEMENT: ❑ Stake Work Done 0`t <br /> PUMP <br /> State Work Done <br /> , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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 fallowing:"I certify that in the performance of the work for which this permit . <br /> I is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." r ' <br /> Contractors 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 will call for a Grout Inspection prior r ting d a final inspection. <br /> Date: <br /> Signed X; e. <br /> (Draw Plot P an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY C <br /> PHASE 1 Date �! L <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout inspection Phase 111 Final Inspection <br /> Inspection By. Date <br /> Inspection By Date <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 /> I' <br /> ..BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> FEE �. <br /> i <br /> LESS <br /> PRORATION <br /> i <br /> [ PLUS _ <br /> t PENALTY <br /> OTHER <br /> OTHER <br /> -713 <br /> - - 77gP.ermlt No c� Issuance Date Mailed Delivered <br /> k Received by, Date Receipt No. <br /> E1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />