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cations Witl Be P ed i Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: U 12 <br /> 01 APPLICATION <br /> J <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> SAM UIN LRONMENTAL HEALTH PERMIT <br /> _r" D1STRZ WATER QUALITY <br /> (COMPLETE IN TRIPLICATE ' <br /> AL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San�oaquin County Ordinance No. 1862-and the rules and regulations of the San J aqS-uuin Local Health District.. <br /> Exact Site Address city, . <br /> Owner's Names L►'r� Phone <br /> Address4CL t` ✓'n City, ,✓ <br /> Contractor's Name r' <br /> si/ License#� d IO r Business Phone A• -� <br /> 2 <br /> ,gyp X31 �• .:c- Emergency Phone <br /> Contractor's Address �3 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No V� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 �Vni <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal FieldCesspool/Seepage Pit Other <br /> Property Line ) Private Domestic Well r Public Domestic Well <br /> INTENDED USE TYPE OF WELL v <br /> ❑ INDUSTRIAL ❑ CABLE TO Dia. of Well Excavation <br /> * DOMESTIC/PRIVATE E) 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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ed State Work Done u <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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 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 I ct prior to grouting and a final inspec <br /> Signed X Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> fi FOR DEPARTMENT USE ONLY <br /> PHASE I ! AV <br /> c�� <br /> Application Accepted By Date <br /> Additional Comments: <br /> ha IIrout Inspection h se II Final Inspection <br /> Inspection By <br /> ' Date inspection By Date �` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 I <br /> REMIT <br /> BASE EXPLANATION :BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT # <br /> FEE S $ <br /> PROLESIf <br /> PRORATION <br /> PLUS # �1 A <br /> PENALTY <br /> OTHER i <br /> ' OTHER <br /> Received by Dal `Y.r. 'Receipt No.— -�-- Permit No. µy Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERM 1601 E.HAZELTO, AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />