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.. .. ..+ .. ..... .err <br /> - Applications Wilk Be Processed When Submitted Properly o - <br /> FOR OFFICE usE: �ARPLACATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> uin Local Health District for a permit to construct and/or install the work,herein described.This application ly <br /> Application is hereby made to the San Joaq <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Saneuin L c IHealth District. <br /> City/Town tet. <br /> Exact Site Address --� <br /> I Phone <br /> Owner's Name11411 11 11,11 <br /> City <br /> Address <br /> I Contractor's Name License# ��� Business Phone <br /> + Emergency Phone <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation I{n�surance on File With SJLHD? Yes__ � <br /> + ION <br /> TYPE OF WORK (CHECK): NEW <br /> LW WE ABANDONMENT OTHERRECONDITION <br /> ❑ ITI P❑P INSTALLATION ❑ PUMP REPAIR❑ <br /> DESTRUCT <br /> WELL CHLORINATION a <br /> REPLACEMENT❑ <br /> O Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer L <br /> Sewage Disposal field Cesspool/Seepage Pit Other <br /> r Property Line_ Private Domestic Well Public Domestic Well <br /> � b <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE <br /> 11D Dia. of Well Casing <br /> DRILLED <br /> ElDOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> [: Type of Grout At I <br /> 1:1 CATHODIC PROTECTION Gd ROTARY <br /> ❑ DISPOSAL ❑ OTHER Other Information �' � <br /> Y <br /> IJ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> El State Work Done <br /> l PUMP REPAIR: Approximate Depth <br /> F DESTRUCTION OF WELL: Well.Diameter <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 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 forwhich this <br /> permit is issued, I shall employ person subject to workman's compensation laws of California." <br /> 1 . <br /> 1 will all for a Gro ons tion to grouting and a final inspection. <br /> Title: Lac Date: <br /> Signed X <br /> {Draw Plot Pian on Reverse Side <br /> FOR DEPARTMENT USE ONLY Q <br /> PHASE I DateS 7 <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection � <br /> Inspection By Date <br /> f Z.�Gf Inspection By��F ' — Date b <br /> �'�' _,'�—��� <br /> Fee IS DUB: ❑ -ANNUALLY - ❑ PER UNIT ❑ PER SITE 13EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31 <br /> RASE EXPLANATION BILLING REMITTANCE- $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t` <br /> PRORATION - <br /> t PLUS <br /> `t. PENALTY - - - <br /> OTHER <br /> OTHER : N <br /> T <br /> Received by <br /> Date Receipt No. P11 5 0. Issuance Date Mailed Delivered <br /> -.. <br /> 1641 E.HAZELTON AVE.,P.O.Bo>f 2409 STOCKTON,CA 952111 <br /> APPLICANT—RETURN ALL CDPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES •- - <br />