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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 /> t 1% A <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S . <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.Tins application is <br /> F made in compliance with Joaquin Count dinance No. 1862 and the Liles and regulations of the San Joaq 'n Local He Ith District. <br /> Exact Site Address 41 City/Town <br /> " <br /> Owner's Name Phone . <br /> Address 0.4 City <br /> Contractor's Name f -C�r/ �Ice' <br /> se Busiriess PhoneContractor's Address mergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No -J <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT.❑r,�..OTHER.© PUMP INSTALLATIO.N.�'...._PUMR-REP_AIR❑.p <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank t .Sewer Lines & 4. Pit Privy <br /> -a-�-@ - -- Sewage Disposal Field Gess oAl/seepage Pit- �ed't- • O er .�- <br /> I — <br /> Property Lin Private Domestic Well Public Domestic Well <br /> INTENDED USE r 'TYPE OF WELL -ia 2- <br /> 13 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Welly Excavation <br /> DOMESTIC/PRIVATE . DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION X-ROTARYJ Type of Grout <br /> ❑ DISPOSAL ❑ OTHER I Other Information <br /> ❑ GEOPHYSICAL ?urface al I stalled By: <br /> a <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump } H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter w Approximate Depth <br /> Describe Material and Procedure <br /> t i <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> t 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 persons:subject to workman's compensation laws of California." <br /> I w'- or rot s tion prior to routing and a final inspection. <br /> Signed X e Title: Date: <br /> T (Draw Plot Plan on Revers ide) <br /> ' f 4 FORD ARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - `` ` t Date 7 g� <br /> Additional Comments: ) <br /> Phase 11 Grou !1 n � a hase III Final Ins action <br /> Inspection By �' �Dat Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH ❑ January,i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE' EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 6 OCZ <br /> FEE <br /> LESS f <br /> PRORATION _ <br /> PLUS f <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> Received by Date i - Receipt No - Permit No Istuance Mte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i ' <br />