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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE Usk: APPLICATION <br /> (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 fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin_ County Orinancoloj. 1862 and the rules and regulations of the San aquin Local Health District. <br /> 'r j� �� l /� �/'>>� ( illi City/Town _ ►?2 A4 <br /> Exact Site Address�� <br /> Owner's Name Co Phone <br /> Address f Clty' <br /> Contractor's Name rL Y� 'License 4_3?211 �_ Business hone <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No o�Q <br /> TYPE OF WORK (CHECK): - NEW WELLkt DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _�d i Sewer Lines<D 1 Pit Privy <br /> Sewage Disposal Field_1Bj"f� Cess poo i/seepage Pik ----••_ Other <br /> Property Line Private Domestic Well D `�— Public Domestic Well <br /> INTENDED USE YTYPE OF WELL �r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_42 <br /> &DOMESTIC/PRIVATE ❑-DR ILLED Dia. of Well Casing r1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 6 1A g S. U V <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout r'T. - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ 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 V) <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 forwhich 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-contr ting signature certifies the following:"I certify that in the performance of the work for which this <br /> permitei , I shallh,mmo ersons subject to workman's compensation laws of California. I <br /> I Gr 1 In n prior to grouting and a sinal inspection. <br /> Signed X Title: ^1 Date: I� <br /> (Draw Plot Plan on R v rse Side) <br /> I. <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI IMS¢. �� �_tL1(�� <br /> Application Accepted By 1-3O ` Date <br /> Additional Comments:- t"- <br /> as 11 Grout Inspection ,P as ill Final Inspec <br /> Inspection By Date��Z� � Inspection By qtLDate S—_z S"g2 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ; [:]'July 1 &Received By July 31 <br /> 1 <br /> ' RE <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT - <br /> - <br /> FEE �1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY] <br /> OTHER <br /> OTHER <br /> L <br /> Received by - ^•' Date Receipt No.- Permit No. - - -- Issuan Date Mailed Delivered r' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �,�,J <br />