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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 /> IPA 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 Count Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address ! a fi v"rj,.,� tI'rit�f .�� -��=7 Ji,,.c City/Town �� ta�Lrr� <br /> J j - <br /> Owner's Name jt �f,��` i t la,ri� t tiiY Phone _ �7j Y V <br /> Address C-Y& ,t raw., D e. .f.4 04 City --';.AL.- ►tr�c r�1� / 5 10 LL <br /> Contractor's Name1 1• `G License# Business Phone <br /> Contractor's Address "7 '/r!j '� �{ s/ 1tU j ire It,_r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ /,_ No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ 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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 914, r„ <br /> JR 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 Lir my r R H.P. t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11 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 persons subject to workman's compensation laws of California." <br /> I will call for a G rout Inspection prior to grouting and a final insp <br /> on. <br /> '�s—o <br /> Title: Date: <br /> Signed X J <br /> ' (Draw Plot Plan on Reverse Side) <br /> OR D ARTMEN7 USE ONLY <br /> PHASE [ / <br /> Application Accepted By- '�"s �f f '� %` Date--" <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE t DATE REMITTED AMOUNT <br /> FEE <br /> LESS 41� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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.Box 2009 STOCKTON,CA 95201 <br />