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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 fora permit to construct and/or install the work herein described.This application is <br /> made in com lianc itq u' Cou y dinan o. 1 g 62 and the rules and regulations of the Sa�+` ,l�gfal He Ith District. <br /> Exact Site Address City/Town �l ^I�� ��/© <br /> Owner's NamDA 0 0i Nh 5t&13 Phone 64 <br /> Address City g _ <br /> Contractor's Nam License Business Phone 1 <br /> Contractor's Address Emergency Phone A� /P <br /> Is Certificate of Workman's Compensation Ins nce on Fil ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WEL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ '� /6 Q / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal eld Cesspool/Seepage Pit Other <br /> Property LinElPrivate Domestic Well -- Public Domestic Well �-- <br /> INTENDED USE TYPE OF WELL <br /> ❑ I STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ElDOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION �❑, GEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION FJ-KOTARY Type of Grout f�1ll yc�w/_ j <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: -� <br /> PUMP INSTALLATION: Contractor —� <br /> Type of Pump H.P. 4-- <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 /> 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." <br /> Contractor' hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> per, s is ed, �Wc ons subject to workman's compensation laws of California." <br /> �1/4ilj�c�all,/or a Gr to grouting and a final inspection. Zd �.47 By <br /> Signed X Title: o "�.-- Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � < i�' c�`4 Date <br /> Additional Comments: <br /> Phase II Grout Inspection�,,,1 Phase III Final Inspection <br /> Inspection By—l->--A--/ Dbf� "�� Inspection By Date <br /> Fee Is Due: ❑ 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Tl S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ­7 P-I N <br /> Received by Date Receipt No. Permit No. IssuancelDate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:8ox 2009 STOCKTON,CA 95201 <br />