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Applications Will Be Processed When Submitted Properly Completed Be SureToSign TheAppllcauon. <br /> FOR OFFICE USE: Co y4 lamoe APPLICATION <br /> + (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) /44t S �_ I T— c�WATER QUALITY Q,/J., bC,S 076"l� � <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. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address C —" City/Town V� <br /> Owner's Name ,' Phone m <br /> AddressS'-_0 � _ City <br /> Contractor's Name �_ rte++ License # !9 3 I 2-1Business Phone <br /> Contractor's Address 3-a a- o"� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes� No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION_❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ) <br /> REPLACEMENT❑ <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 /> INTENDED USE TYPE OF WELL n, <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 Installed By: <br /> PUMP INSTALLATION: ,, Contractor "ZIM <br /> Type of Pump ? ✓ I H.P. � ; <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done Qo___e 0.W " 1 A <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth N <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 /> Homeowner or licensed agent'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.' <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 /> I will call for a Grout Insp do r grout g and a final inspection. l a <br /> Signed X" itle: Date: �-✓ <br /> ((Draw Plo Ian on Reverse Side} <br /> F R D ARTMENT USE ONLY <br /> PHASE - <br /> Application AcceptedDat Zz <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Assuancb Date Mailed Delivered S � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />