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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. } <br /> FOR OFFIC.E USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL til <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY }>> <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applica 'on is-_ <br /> made in compliance with Sanaquin Co my Ordi n e No 1862 a the rule qnd r gu ations of the San Joaq in Local He Ith District. �`tJ <br /> Exact Site Address q/Town <br /> _ <br /> Owner's Name r Phone Y,33(76 <br /> Address City �b tt <br /> Contractor's Name t�1 License# . Business Phone <br /> Contractor's Address Emergency Phone c5_b"-/9cZ7Z <br /> Is Certificate of Workman's Compensation I_nsurance on File With SJLHD? Yes_V No <br /> TYPE OF WORK (CHECK): NEW WELLID'urDEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well r <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation - a <br /> r/ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑,,RIVEN Gauge of Casing 3 <br /> IRRIGATION ud'GRAVEL PACK Depth of Grout Seal AeV72 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information T(11dMQL) <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> f <br /> PUMP REPLACEMENT: ❑ State Work Done { <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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. p <br /> Homeowner 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." 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work forwhich this I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> I wil call for a Gr ut&1ection prior to routi nd a final inspecllon. <br /> Signed X Date: 7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPAR76r <br /> T USE ONLY <br /> PHASEI <br /> Application Accepted By ( Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection, hase III Final Inspection <br /> Inspection By Date Inspection By Date r2 ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LdYPER SITE ❑ EACH ❑ January 1 &Re ived By January 31 ❑ July 1 &Received By July 31 <br /> SICCING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> /ah VZ27 17I L( P-11V I, <br /> Received by_ _� - C)at4 Receipt NOL Permit No. -. ,.r-ssuance Date _ Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO:= ENVIRONMENTAL PERMIT/SERVICES t - 1601 E.-HA2FELTON AVE.,P.O.Box 2009 -'^STOCKTON,CA 95201 -� <br />