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Applications Will Be Processed When Subm4led Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: 1/ / APPLICATION <br /> (6 Y+1 4� (For Non-Transferable, Revocable,Suspendable) y/ <br /> 0 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862nd the rules and regulations of the San Joaquin Loc I Health District. <br /> Exact Site Address QST S City/Town 6 <br /> Owner's Name Phone <br /> ~/ .t City— <br /> License <br /> Address <br /> Contractor's Name `� 0&G� License# 15 �`�_�Business Phone ' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on f=ile With SJ HD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN D RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR r �y <br /> REPLACEMENT❑ v-r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property.Line Private Domestic Well Public Domestic Well <br /> d <br /> INTENDED USE TYPE OF WELL <br /> 1:1 INDUSTRIAL 1:1CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTiC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> 11 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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump " r ,6 H.P. sI <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done a♦.e c � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> iI hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i 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 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." <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 ill calf for a Grout Inspection 'or outin and a final inspection. <br /> Signed ]N w� itle: ?"a1 Date: � <br /> F (Draw Plot Ian' on Reverse Side) <br /> FOR DEPARTMENT USE ONLY Ip f <br /> PHASE 1 <br /> Application Accepted By Dates-- <br /> Additional Comments: <br /> Phase H Grout Inspection Pha Ill Final Inspection <br /> Inspection By Date Inspection By Date �U <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT © PER SITE El EACH El January 1 &Recei y,January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE YDATE REMITTED C AMOUNT <br /> FEE 4�� 4 V <br /> LESS Y <br /> PRORATION <br /> PLUS <br /> PENALTY !! - <br /> 'r OTHER E <br /> OTHER <br /> ReceivedbyDafe Receipt No. - Permit No. Iss ante D to Mailed Delivered <br /> f. APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTAL.HEALTH PEAMITISERYICE$ 1601.E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,GA 95201 <br />