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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) <br /> 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 compliance with San Joaquin County Ordinance o. 1862 and the rules and re Xpi <br /> of the Sa/ �9aquin Local Health D' trJ'ct. <br /> Exact Site Address„!,G all- ��rt��VFrtr4s Tye 4j0Q Z4), 0� l un/Car �'r Ad' <br /> Owner's Name v Phone 9 i � <br /> Address City ijei,v AI <br /> i <br /> Contractor's Name License#,? V Business Phone <br /> Contractor's Address ]3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 0, DEEPEN ❑ RECONDITION❑ DESTRUCTIONE] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ j i <br /> DISTANCE TO NEAREST: Septic Tank 04 Sewer Lines� � Pit Privy <br /> Sewage Disposal Feld T�,p !� Cesspool/Seepage Pit Other <br /> Property Line& 4--Private Domestic Well s56 '-(.- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIALCABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> &ATHODIC <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �� 4RIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r.�1:,ilz/2 <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 /> 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's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persosubject to workman's compensation laws of California." <br /> I w' a„ fora ul Ipkctio pr" "r to grouting and a final inspection. <br /> Signed XTitle: Date: ,�/.z 1" �) <br /> (Draw Plot Plan on Reverse de) <br /> OR PARTMENT USE ONLY <br /> PHASE1/ <br /> F <br /> Application Accepted By Date 0 <br /> Additional Comments: <br /> Phase II Grout Inspection PhaagelIIA al Inspection j <br /> Inspection By Date Inspection By to 'of* ,G+w <br /> d- <br /> ✓ zem . <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3 July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION.111 D TE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � S 9 's N �1 <br /> Received by Date Receipt No. Permit No. I uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />