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Alications Will Be Processed When Submitted ProperlyCompleted. tieSure Tosign IneAppTICi7uUn. <br /> pP <br /> FOR OFFICE 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 per <br /> mittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis �+ <br /> made incompliance with San Joaquin County Ordinance No.1862 and the xules and regulations of the San Joaquin Local Health District. Q <br /> Exact Site Address rl —`f City/Town _0 <br /> Owner's Name Phone <br /> Address 3 '30 City _ <br /> Contractor's Name _ License ZP7f Business Phone a E <br /> Contractor's Address <br /> Emergency Phone <br /> -is Certificate of Workman's Compensation Insurance on File ith SJLHD?. -Yes.�� No <br /> TYPE OF WORK(CHECK): NEW WELL 11 DEEPEN El RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field- Cesspool/Seepage Pit Other I <br /> Property Line - Private Domestic Well Public Domestic Well II <br /> INTENDED USE rt TYPE OF WELL <br /> i <br /> ❑ INDUSTRIAL _ ~❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 'f ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL OTHER <br /> ❑ Other Information <br /> I ❑ GEOPHYSICAL r Surfac Seal Instplled By: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I� DESTRUCTION OF WELL: ' Well-Diarmeter Approximate Depth �. <br /> k DescribeMaterial and Procedure s <br /> I —.1w. .i <br /> Aw <br /> I hereby.certify that.l have prepared this application and that the work will be done in accordance with San Joaquin Cdunfy <br /> e ordinances state laws, and rules and regulations of the San Joaquin Local Health District. i . <br /> E <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for whish this permit 3 <br /> is issued, I shall not employ any person!in such manner as to become subject to workman's compensation laws of California:,' l <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this € F <br /> k# permit is issued, I shall employ persons subject to workman's compensation laws of California." =r <br /> ill cal a Grout I pection prior to-,grouting, and a final inspection. ��' <br /> Signe }$ Title:_ Prr. �� _ Date:. <br /> (Draw Plot Plan on-Reverse Side) <br /> k { <br /> j FOR DEPARTMENT USE ONLYf _ i <br /> PHASE I <br /> Application Accepted By date <br /> 4 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 1 I Inspection, j <br /> " Inspection By <br /> Date II Inspection By Date <br /> 113 8bx <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REM ITI <br /> I BASE ExPLANATIpN BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . DATE DATE REMITTED AMOUNT <br /> 4 <br /> I FEE <br /> LESS i <br /> PRORATION _. <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -�- ,Date � � ReceiphNo, Permit No. �` Issuance Date - Mailed Delivered <br /> "�,u. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES (/` r) X1801 E.HAZELTONAYE.',P.0.80.2009 STOCKTON,CA 95 j <br /> iw� <br /> 9 —4- 41 <br />