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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ICE USE: C / APPLICATION <br /> D (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN RIPLI :ATE) WATER QUALITY `£ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin CountyOrdinance No. 1862 an the rules andg regulations of the San Jo a n ocal//��`�e Ith District. <br /> Exact Site Address :?y e9 AA61n 49City/Town �C <br /> Owner's Name c)4� _ AL <br /> Y? Q ivl-z i Phone <br /> Address ltlll Pto c 7r City f� <br /> Contractor's Nam .. _ License# ca—�?� Business Phone �� <br /> Contractor's Address /►47 Emergency Phone _ v <br /> Is Certificate of Workman's Compensation Insurance on�Flle With SJLHD? Yes NoTYPE OF WORK (CHECK): NEW-WELL❑ DEEP ❑ RECONDITION❑ DESTRUCTION❑ ^ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <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 <br /> INTENDED USE TYPE OF WELL `° —{it <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well 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 ❑ ROTARY Type of Grout ! „ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ) <br /> Type of Pump Se, b M 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil call for a Grout Inspection or g and a final inspection. <br /> Signed X Itle: Pr's Date: 30 <br /> (Draw Plot Flan on Reverse Side) <br /> 7RD ARTME T USE ONLPHASEApplication Accepted ByZ -"� Date `� ? <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `7 9.-g-71 8l3c5s1-75 <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />