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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FtR 00 E USE: ,r APPLICATION <br /> { (For Non-Transferable Revocable,Suspendable) I I) <br /> .�,, ...._ �. ..,. PUMP&WELL <br /> r ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <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. 18 2 a d,the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address 13I- __ City/Town <br /> Owner's Name A Phone <br /> Address �IfTR City <br /> Contractor's Name License#J* 4 y Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes__X_ rNo <br /> TYPE OF WORK (CHECK): NEW WELL D& DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ �y <br /> DISTANCE TO NEAREST: '-Septic-Tank—���="Sewer Lines ` Pit Privy �} <br /> Sewage Disposal Field Cesspool/Seepage Pit 'I Other ' <br /> Property Line-SD • Private Domestic Well MtQn1d 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 " k <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION © 'ROTARY Type of Grout �ns <br /> IoL'd <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal.Installed By: <br /> PUMP INSTALLATION: Contractor_ <br /> Type of Pump _S . _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> r 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 issue, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X �'� r l/1,Z 0!(]�-% Title: `iD l <br /> _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> • � <br /> FORDEPART ENT USE ONLY <br /> PHASEIApplication Accepted By "'� 4't-") Date Q /7 7/ <br /> Additional Comments: <br /> Phase 1 Grout Inspection Phase,41 Final Inspection <br /> . d�"z r <br /> Inspection By— t � � Date �. Inspection By Date�/� <br /> Fee Is Due: ❑'ANNUALLY ❑ PER UNIT IS PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> { BILLING REMITTANCE $ REMIT 9 <br /> . '`BASE;�, EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT r <br /> FEE <br /> LESS z <br /> PRORATION <br /> f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ti <br /> OTHER <br /> ^`11 10 17 7 } <br /> Received by Date ReceipttNNo,- Permit No, Issuance Date Mailed Delivered <br /> s., APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT!SERVICES 1601 E:HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />