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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: 1 y��J APPLICATION <br /> �0 V 1� '�! (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Copuntt)Ordi ante No. 1862 a 'd the rules and regulations of the.San Joaquin Local ealth.District. <br /> Exact Site Address °�+ k City/Town r Y <br /> Owner's Name f `moi r A Phone <br /> Address _ � <br /> ity 1— <br /> f ✓w .. . �._ s}:v. License Busineis Phoret , � 4 <br /> Contractor's Name "Emer ency Phonel-: <br /> Contractor's Address o <br /> ' <br /> J <br /> Is Certificate of Workman's Compensation Insurance o File With SJLHD_? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL LLDE PEN ❑ RECONDITION lJ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑, PUMP INSTALLATION ❑ - PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank t Sewer Lines Pit Privy <br /> Sewage Disposal Field' - ---LrCesspool./Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well j <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 <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 Bey: <br /> PUMP INSTALLATION: Contractor L <br /> - – H.P. U <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done- <br /> a � <br /> PUMP REPAIR: State Work Done J <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 tz . <br /> 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. *. <br /> Home owner 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 certify1hat 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 tor'a Grout In n rio- o�louting d a final inspection.,.: '. ~ <br /> Signed Q Title: Date: <br /> (Draw PI Plan on Reverse Side) <br /> FOR DEPARTMENT USE'ONLY '" 3 <br /> PHASE I 06 <br /> Application Accepted Sy Date <br /> 4 <br /> Additional Comments: <br /> Phase 11 Grout Inspection F�haA 111 Fina nspection <br /> {� J�✓ <br /> o 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 1 31 <br /> ' =REMlT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE' <br /> LESS i <br /> PRORATION ! <br /> s _ <br /> PLUS { ` <br /> PENALTY - <br /> -« w <br /> OTHER - 'T ' <br /> OTHER <br /> s Received by Date Receipt No. Permit No.. - {Is s ante ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT N AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />