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ApplicationsWill BeProcessedWhen Submitted.Property Completed. Be Sure To Sign The Application, F <br /> ,,FOR Gf-FICE'USE: APPLICATION, 1� <br /> v (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 JoaquinCo my Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address City/Town <br /> Owner's Name Cbt-II �( Phone <br /> Address 0 City <br /> Contractor's Name O w. License# *72-r-Business Phone__. 7e.Contractor's Address �' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes _ No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ `J <br /> - 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ ''PUMP REPAIRS r <br /> REPLACEMENT❑ Wr <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Wt <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �l <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ <br /> ❑ INDUSTRIAL ❑ CABLE 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 Install By: <br /> PUMP INSTALLATION: Contractor G� <br /> Type of Pump_ -T&,6 ^a r J H.P.P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done. aCo <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> K <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 licensedagent's signature certifies the following:"I 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." ,I <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 call for a Grout Inspectio or grout! a d a final inspection. W <br /> Signed <br /> Date: <br /> (Draw Plot Plan n Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By 4 <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> Inspection By r, Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J uary 31 ❑ July 1 &Received By July 31` <br /> BILLING REMITTANCE $ REMIT ' <br /> BASE EXPLANATION DATE DATE RE AMOUNT DUE CHECKED i <br /> AMOUNT <br /> FEE S <br /> LESS {' <br /> PRORATION ✓'"�d� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit go, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />