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resAppliCations Will Be Processed When Submitted Properly Completed. Be Sure Td-Sign The Application. <br /> rOl oF1=fcE USE: F - " APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL j <br /> k (COMPLETE IN TRIPLICATE) WATER QUALITY Z LP <br /> ._ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalI the work herein described.This application-is <br /> made in compliance with San Joaquin. ounty.Ordin, e No. 1862 and-the.rules and regulations of the San <br /> Jo quin'Local Health District. <br /> Exact Site Address. 1' �t <br /> own <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name ti icense 4Business Phone <br /> Contractor's Address Emergency Phone s <br /> 74f 7 <br /> Is Certificate of Workman's Compensation Insurance on File W SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIO''Y• W Ely <br /> REPLACEMENT❑ �'� PUMP REPAIR <br /> " DISTANCE TO NEAREST: Septic Tank " + <br /> P Sewer Lines _ Pit Privy- <br /> Sewage <br /> rivySewage Disposal Field Cesspool/Seepage Pit Other ;. <br /> Property Line Private Domestic Well Public Domestic Well C <br /> INTENDED USE TYPE OF WELL <br />{ ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE �❑ DRILLED D T A Dia. of Well Casing <br /> ElDOMESTIC/PUBLIC ❑DRIVEN <br /> Gauge of Casing YA <br /> N IRRIGATION 11 GRAVEL PACK - Depth of Grout Seal ; <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> 11 OTHER <br /> Other Information ', <br /> C1 !GEOPHYSICAL Surface Seal Installed By: <br /> y`r <br /> PUMP INSTALLATION: 7Cs <br /> Contractor f <br /> Type of Pump= H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: - ❑_State Work Done <br />`~ DESTRUCTION OF WELL: <br /> :Well Diameter- <br /> `% Approximate Depth "± " <br /> :Describe Material,and.Procedure <br /> I hereby certify that I have preps er d this'application and that the°work will be-done-in accordance with San Joaquin.County <br /> ordinances, state laws`artd rules and regulations of the San Joaquin,Local_Health District. <br /> Home owner or licensed agent's signalure•certifies the follpwing:"I certify that in the.performance of the.wor"k 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." I µ <br /> Contractor's hiring or sub signature certifies the following:"I certify that in the performance of the work forw- hick this t <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'"grliuting anana a final i snot i pectlon. <br /> � i <br /> Signed X F f <br /> Title: i Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By o,"IAL <br /> Additional Comments: " <br /> Date iZ 7 <br /> Phase 11 Grout Inspection PhaS III Final Inspection Y <br /> Inspection By Date Inspection By Date Z O <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE vto <br /> AMOUNT <br /> t <br /> LESS <br /> PRORATION 1} <br /> PLUS yq k <br /> PENALTY -� <br /> OTHER " , <br /> OTHER <br /> —741— 17B\r_cJ <br /> Received by Date Receipt No Permit No. Issuance DateZ Z <br /> Mailed elivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES�.� - � 1601-E..HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA <br />