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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> y (For Non-Transferable, Revocable,Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) `�p O Lf 1,_1. kj&Kw4�e WATER QUALITY ! t qa-01 <br /> Application is hereby made to the San Joaquin Local Health Distric#fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wl h Sy Joaquinount Ord'n nce No. 1862 and the rules and regulations of the San Joaquin Lo ai Health District. � <br /> _�� 1 <br /> Exact Site Address, I �r City/Town <br /> Owner's Nam J p _ <br /> Phone <br /> Address City <br /> Contractor's Name _ __ t5l, lto ��(?,� License Business P one <br /> Contractor's Address Emergency[Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION I DESTRUCTION❑ (,� r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR Ll t <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �44p Sever Lines Pit Privy <br /> Sewage Disposal Field�_�'_Q_ Cesspool/Seepage Pit �-- Other <br /> Property Line Private Domestic WeII Public Domestic Well <br /> INTENDED USE TYPE OF WELL 4 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation , <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing N <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 9 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ 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 /> 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 p r <br /> ons subject to workman's compensation laws of California." <br /> Ill fora ut pec rior to grouting and a final inspection. f <br /> Signed X Title: Date: 14� <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY yy <br /> PHASE o <br /> Application Accepted By. ll <br /> Date��� <br /> Additional Comments: <br /> Phas II Gro t Inspection gg Phase IJPFinal Inspection _ <br /> Inspection By Date.. Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t L <br /> LESS f <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ,10 <br /> Received by Date Receipt No Permit No I Issuan a Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />