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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTneAppllcanon. i <br /> WPLETE <br /> : APPUC_AT'ON <br /> I <br /> (For Non-Transferable, Revocable,°Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT -� 1 <br /> LICATE) WATER QUALITY r.r" � y10 <br /> t 1 tpna „+{ r zfl <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installthework herein described.This application is <br /> Sir <br /> made in compliance with San Joaquin County Ordinaplce o. 1862 and the rules and regulations c, the San Joaquin Local Health District. <br /> Exact Site Address j City/Town <br /> Owner's"Naive ' � —�L 1.�� 'SCF e .: Phone <br /> Address <br /> r " * r"License#7�J Business"Phone �3 SI " <br /> Contractor's Name 1 <br /> Contractor's Address Erieegency Phone ' <br /> Is Certificate of Workman's ompensation Insurance on Fil&ith SJLHD? Yes No <br /> TYPE'OF WORK (CHECK): NEW WELL'❑ DEEPEN❑ _RECONDITION❑` " DESTRUCTION❑ �V <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR I <br /> REPLACEMENT❑ , <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic-Well Public Domestic Well s <br /> INTENDED USE TYPE OF WELL { <br /> ❑ <br /> INPRIAL ❑ CABLE TOOL. " Dia. of Well Excavation 1 <br /> UJ-fOMEST]6/PRIVATE ❑ DRILLED "Dia. of Well Casing j <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> f r <br /> ❑ IRRIGATION 13GRAVEL PACK "Depth of Grout Seal <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL C Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i PUMP REPAIR: -K State Work Done <br /> DESTRUCTION OF WELL: Well Diameter f I Approximate Depth J <br /> Describe Material and rocedure, <br /> I hereby certify that I have prepared this application and that the work will be done ih accordance with San Joaquin County p, <br /> ordinances, state laws, and rules and regulations of,the San Joaquin Local Health District. W <br /> Homeowner or licensed agent's signature certifies the following:' 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 lorwhi*hthis <br /> f4" permit is issued, I shall''employ persons subject to workman's compensation laws of California." <br /> t I will C"If a Grout 1n tion prior to grouting and a final inspection. � , . I t <br /> Signed Title: Date: <br /> (Draw-Plot Plan on Reverse Side) <br /> r FOR DEPARTMENT USE,ONLY ` <br /> j PHASE I <br /> Date <br /> F-Application Accepted By u <br /> Additional Comments' <br /> Phase II Grout Inspection Ph s MI"Final Inspection <br /> inspection By Date Inspection B- .. Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PERSITE ❑-EACH '❑ January 1 &Received By January 31 '❑ July 1,&ReceiveRd N July 31 <br /> IT <br /> BILLING, ___- REMITTANCE $ AMOUNT DUE CHECKED _ <br /> BASE " EXPLANATION' DATE DATE REMITTED C AMOUNT <br /> r FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Received by Date . Receipt Nu... Permit.No `.kss anc pal _Mailed. Deli"vered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.90■2000 STOCKTON,CA 96201 <br />