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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY <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 /> I made in compliance witch/Sawn Joaquin Count , rdina ce No.,1862 and the rules and regulations of the'San Joaqui cal Health District. <br /> Exact Site Address L �-v�� - t City/town � � r_1A_,i-- <br /> y00, <br /> Owner's Name N m /1 �' Phone <br /> Address City` <br /> Contractor's Name ibr4=407& License# 7�usiness Phone. <br /> Contractor's Address Emergency Phone <br /> Is Certificate of W_orkman's Compensation Insurance on File With SJL D? Yes No <br /> TYPE OF WORK (CHECK):' 'NEW WELL❑ 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 DomesticWellPublic Domestic Wel! <br /> INTENDED USE a TYPE OF WELL e� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Wel! Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER Other Information �. <br /> ❑ GEOPHYSICAL Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor �� ) <br /> Type of Pump Pf 2dZ - H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> r PUMPRi_ 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 f+,� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local.Health Distr* } <br /> Home owner'or licensed agent's signature certifies the following'I certify that in the peltirmance 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 wil cal for a Grout Inspection ri g uti gand a a ins ection}.� <br /> Signed ti/i�' Date: <br /> `(Draw Plot PI on Reverse Side) <br /> f <br /> FOR DEPARTMENT USE,ONLY <br /> r <br /> '-_PHASE I <br /> Application Accepted ByI if(+y�� �� Date <br /> Additional Comments: <br /> 'Phase II Grout Inspection ease III Final Inspection <br /> Inspection By Date '.Inspection By 7��`�+�-� ate- <br /> Fee <br /> teFee Is Due: 13 ANNUALLY ❑ PER UNIT _❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> I BILLING RE=MITTANCE _ $ 'REMIT <br /> BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> � ��AMOUNT ' <br /> I FEE `CILA CA - <br /> a T <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER f <br /> OTHER _ <br /> I <br /> �r Received by Date Receipt No. Permit No. Issuance ate. Mailed '.Delivered <br /> j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />