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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) ' <br /> _ PUMP&WELL <br /> 4" A� ENVIRONMENTAL HEALTH PERMIT <br /> I ATE I "I' Chi ` <br /> (COMPLETE IN TRIPL C ) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is . <br /> made in compliance with San Jpaquin County Ordinance No.1862 and the;rules a regulations of the San Joaquin Local Health District. <br /> '' rI• 1M`. <br /> City/Town�1 <br /> Exact Site Address <br /> Owner's Name 3 cs a h /�A -_ Phone Vle.- -75 S_9 4. <br /> Address j City <br /> Contractor's Name O + e�s� License#[�L� Business Phone ' 7 L <br />` Contractor's Ad4 _,�s Emergency Phone �J r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL&-' DEEPEN ❑ RECONDITION❑ DESTRUCTION[] ? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ J} <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ;7 Pit Privy t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Fr <br /> ❑ INDUSTRIAL f ❑ CABLE TOOL Dia, of Well Excavation <br /> L C��MESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> F DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing '�_ �� <br /> �RIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION B-AtTARY Type of Grou �I <br /> ❑ DISPOSAL ❑ OTHER Other Information O� <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump `: . H-P. <br /> .PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I <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 comperisation laws of California." <br /> ( Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the pertormance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a Grout Inspection prior to grouting and a-final inspection_ <br /> f_ <br /> Signed X L�/$ = `x Title: L� i m Date: <br /> (Draw Plot Plan on Reverse'Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE - 1 <br /> Application Accepted By U Date <br /> Additional Comments: <br /> h e!I Grout Inspection ha Ill Final lnspection� /y <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE. EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r FEE . -- <br /> t LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by-'-..,.- D to Receipt No +i^- Permit No:----� ,� Issuance Date Mailed Delivered _ <br /> APPLICANT—RETURN-ALL COPIES-TO:_ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />