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r F _ ppncauonsWill BeProcessed When Submitted Properly Complete e b n <br /> FOR:OFFICE USj17 � !� slag hellApAPPLICATION { <br /> (For Nan-Transferable Revocable,Susi lei JUN 12, <br /> f5�� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL , <br /> (COMPLETE IN TRIPLICATE WATER �lAUTr SAN JCAQJ <br /> fN LOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or i I.�1� L�1I TTpp��+ <br /> made in compliance with n J quipCou rdinance,No. 1862 andT�Wbrelr1`tfes�ribed.This application is Y <br /> Exact Site Address 4 � 0�� kyles and regulations of the San Joaquin Lo of al���ss�ttr' t J <br /> City/Town / /e�N Y7r3 <br /> Owner's Name1►+ <br /> Address �rj S,r Phone <br /> Contractor's Name d—7 �1 U i1-f S City <br /> Contractor's Address = License# Business Phong <br /> Is Certificate of Workman's Compensation insurance on File With SJLHpmergency Phone ,� — <br /> Yes No <br /> TYPE OF WORK (CHECK): NEW WELL L3DEEPEN ❑ <br /> RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER LY PUMP INSTALLATION ❑ PUMP REPAIR❑ QV <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank1 <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field_ Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> ❑ INDUSTRIALTYPE OF WELL <br /> ❑ <br /> DOMESTIC/PRIVATE ❑ CABLE TOOL Dia. of Well Excavation <br /> 13DRILLED Dia. of Well Casing <br /> C3 DOMESTIC/PUBLIC ° <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION <br /> C1 GRAVEL PACK <br /> ❑ CATHODIC PROTECTION ElDepth of Grout Seal <br /> C3DISPOSAL ROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION- Contractor Surface Seat Installed By; <br /> J <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done H.P. °CI <br /> PUMP REPAIR; tate Work Don 4 <br /> DESTRUCTION OF WELL: Well Diameter {� <br /> Describe Material and Procedure roximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j <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' Ing or sub-contrac 'ng signature certifies the following:"I c fy that in the performance of the work for which this <br /> pe i is ed, I S II emplo per s ns subject to workman's compe a ' n laws of California." <br /> I ill Inspecti prio o routi g and a final inspect' <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE <br /> FO DEPART ENT USE ONLY <br /> Application Accepted By <br /> Date <br /> Additional Comments: t <br /> Phase It Grout Inspection Phase III Final Inspection <br /> Inspection By Date <br /> Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received Ry July 31. <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE �.� <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY' <br /> OTHER"-- <br /> OTHER <br /> Received <br /> Receipt No. Permit No. Issuance Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES HMailed Delivered �- <br /> 1601 E. AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />