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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Tran§ferable,'Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL,HEALTHPERMIT JO-T-- 1 <br /> (COMPLETE IN TRIPLICATE) 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 with San Joaquin Cou <br /> ty Ordinance No. 1852 and the rules'and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/To <br /> Owner's Name Phone 63S_ <br /> Address e;Z K"` City <br /> Contractor's Name Lt License# .7� Business Phone. <br /> r Contractor's Address Emergency Phone' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK)~ —NE1N WELL❑�"DEEPEN ❑ A REGONDITION❑- � DESTRUCTION❑ <br /> WELL.CHLORINATION 0 _ WELL.ABANDONMENT.❑ OTHER ❑ PUMP INSTALLATION 9;--PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑- IIN USTRIAL 11 CABLE TOOL _. Dia. of Well Excavation <br /> , <br /> L�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 /> ❑ <br /> GEOPHYSICAL.__ Surface Seal installed By: <br /> PUMP INSTALLATION: i Contractor �� <br /> t Type of Pump ,. H.P. <br /> PUMP REPLACEMENT:, ❑ State Work Don <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate'Depth <br /> - r 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 following:"I certify that in the performance of the work forwhich 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 /> a <br /> I will ca r a Grout Inspection prior to grouting and a.final inspection. <br /> Signed X. Title:, Date: Z` ' <br /> (Draw Plot Plan on Reverse Side) I <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I - --4- <br /> Application <br /> -L Application Accepted By I Date ' <br /> Additional Comments: <br /> Phase lI Grout Inspection t` Ph Final Inspection ;L <br /> Inspection By Date Inspection ByDate <br /> S <br /> Fee Is Due: ❑ ANNUALLY '❑,PER-UNIT' ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31. ❑ JOy 1 &Received By Ju#y 31 - <br /> - ; NCE $ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> R DATE DATE REMITTED AMOUNT <br /> FEE yr r U_ <br /> LESS <br /> PRORATION <br /> } <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by. - Date Receipt No.- _ Permit No.. ... _ Ilisuance Da,e - Mailed Delivered. ._ <br /> APPLICANT=RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />