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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheAppncauon. <br /> FOR OFF?iCE USE: <br /> APPLICATION <br /> y 4; (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) 1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct andlor install the work herein described.This applicatioIS <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules land regulatio s of the San Joaquin Local Health District. <br /> Exact Sit�_Address lQ Z�� � ��� r f */� /Town h ' <br /> Owner's Name L1�/�?�/`�I��.�� Phone <br /> Address* G2c? � rrz�l '�� City <br /> Contractor's Name -S License# „')176X/.: Business Phone <br /> Contractor's Address <br /> /,-:)"I J /Z/p rS�# Emergency Phone �� 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL)4 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Vrn" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ r <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 ` r� <br /> 1❑d INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> — <br /> $ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION Icy GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> C3 GEOPHYSICAL Surface Seal Installed By: <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 1 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 will call for a Grout Inspection prior to grouting and a_final inspection. <br /> Title: Date: 5_161 <br /> 8r <br /> Signed X ' <br /> �(D Plot Plan on Reverse Side) <br /> 6 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph a ro t lospectio�f L'�/ Phase III Final Inspection <br /> Inspection By w Date / /J / Inspection By Date <br /> I Fee is Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 8 Recei y January 31 13 July 1 8 Received By July 31 _ <br /> wr REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate 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 />