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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR„OFKJ:E USE: APPLICATION <br /> - (for Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT /_0 T 1 <br /> COMPLETE IN TRIPLICATE) WATER QUALITY } <br /> WATER <br /> €. ¢.. r• <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described-This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. .: <br /> Exact Site Address �.✓lc d ” City/Town <br /> Owner's Name Rhone <br /> Address nr �• _ City < ,, <br /> Contractor's Name _ � " "r 1' 'License.#u3f 7_t''` Business Phone,,15-3-1) <br /> Contractor's Address e ' 'r, �'?Erh rgency•Phone;' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__L No <br /> TYPE OF WORK (CHECK): "'NEW WELL❑ �_ DEEPEN ❑-;'-''RECONDITION`❑` --- DESTRUCTIONIN❑'-' -- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ J <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy J <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <br /> i ❑. INpkJSTRIAL - ❑-CABLE TOOL Dia. of Well Excavation <br /> I&/DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Q ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: a' <br /> I PUMP INSTALLATION:: Contractor 0,4 <br /> Type of Pump H.P, �y <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 hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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:'1 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> I willCA,II for a Gro t Inspection prior to grouting and a final inspection. <br /> Signed X r. `; Title:. Date: <br /> -(Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY I a <br /> P <br /> _ 1 r.. _ <br /> HASE . € . . . 7 /_ 9 <br /> /2, � <br /> r r Application Accepted By Date <br /> Additional Comments: t I <br /> Phase 11 Grout Inspection P e final Inion ����✓ <br /> Inspection By Date Inspection By -Dati.e <br /> Fee is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE'-- ❑ EACH -❑ January 1 &neceiv6d By January 314-- ❑ July 1 8.Received By July 31 - <br /> k i BILLING REMITTANCE _ _ $: ' REMIT <br /> BASE'' - EXPLANATION - AMOUNT DUE- CHECKED <br /> i t I. / DATE s DATE REMITTED' AMOUNT _ <br /> : FEE <br /> LESS , <br /> PRORATION <br /> .. .PLUS <br /> PENALTY- <br /> OTHER - — <br /> OTHER <br /> ...Received by - - Date —.L-, ,,.+.,--- Receipt No. „.__.. .Permit No. ,� .. ..� _ suance D le'.) Mai4ed Delivered <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> 1 ' <br />