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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignfheWplrl�abZn._7 -r' V---' J <br /> FOR oFFlce 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 tothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San J quin Coun Ordi nce No. 1662 and t e rules a d regulations of the San J Local Health District. <br /> 1 +..;, Cit /Town <br /> Exact Site Address �� y <br /> Owner's Name Phone <br /> .r. <br /> Address 1L.-- city <br /> Contractor's Name License#�L111 E14I Business Phone 9 '�7j:- <br /> Contractor's Address ` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELD+` DEEPEN 11 RECONDITION❑ DESTRUCT1Of <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP iNSTALLATION)Z PUMP REPAIR J <br /> REPLAC€MENTO a, '� <br /> y �� <br /> DISTANCE TO NEAREST: Septic Tank y Sew�r Lines Pit Priv <br /> Sewage Disposal Field?i 'rt__a .c„� Cesspool/Seepage Pit Other <br /> vLrta�+Y9;,, p operty Line Private Domestic Well i l� Public Domestic Well ! <br /> 1 <br /> INTENDED USE TYPE OF WELL, e0e <br /> ❑ INDUSTRIAL , ❑ CABLE TOOL Dia. of Well Excavation .j <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f <br /> DOMESTIC/PUBLIC^ ❑ DRIVEN Gauge of Casing r <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal , <br /> ❑ CATHODIC PROTECTION ROTARY ':. Type of Grout <br /> ❑ DISPOSAL ❑ OTHERS- Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: CG -� <br /> ' <br /> PUMP`1NSTALLATION: Contractor <br /> ; .� <br /> Type of Pump t ' H.P. <br /> PUMP REPLACEMENT, ❑ State Work Done' 02 44,2 <br /> PUMP REPAIR: ElState Work Done' <br /> '"sr " <br /> DES ��.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 'I-h0reby certify that I have prepay this application and that t work will 6e done in accordance with San Joaquin County I <br /> ordinances, state laws;and-rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifles 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 maniier,as to'become subject to workman's compensation laws of California." <br /> Contractors hiring orsub-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 Californian + <br /> I will call;for a Grout Inspection prior to grouting and a flnai inspection.,, 1� , �-.11 <br /> Signed X �� Title: /�!37 � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> �. <br /> .. ...-'FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By '- Z Date <br /> Additional Comments: Y <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Dale 4 ',I_j <br /> Fee Is Due:13 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH. - ❑.January.1 &Received By January31,­ ❑ July 1 &Received By July 31- <br /> _.. . .. REMIT <br /> 'BILLING REMITTANCE <br /> f BASE� .— EXPLANATION REMITTED <br /> AMOUNT DUE CHECKED <br /> a, GATE DATE AMOUNT <br /> FF s <br /> FEE ,.�j <br /> f Q 1;11 . <br /> LESS <br /> ii PRORATION - f <br /> PLUS I 0—Lr4L tv&.v / i 1 Gtc �c +— <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. yssuanceDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />