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Applications Will BeProcessedWhen SubmittedPropeny L;omplerea. tse aure Ioargn rneHppu4anvrr. <br /> APPLICATION <br /> FOR OFFICE USE: fe1�. �� oaQ <br /> (For Non-Transierable, Revocable, Suspendable) <br /> 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 permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin L,5al Health District. <br /> Exact Site Address d 0 City/Town CS <br /> Owner's Name �' rD2 Phone <br /> Address a ++6 City S A— <br /> r- <br /> Contractor's Name License# /*a-7 Business Phone <br /> Contractor's Address Emergency on <br /> Is Certificate of Workman's Compensation Insurance on Fileith SJLHD? Yes— /� No <br /> 5 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ tttf���� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <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 In alled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 41 W I" H.P. �✓ <br /> PUMP REPLACEMENT: © State Work Done <br /> PUMP A"'Al V State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material arid 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 for which this <br /> permit is issued, 1 shall employ persons subject to workman's-.Compensation laws of California," <br /> I�WPI call for a Grout Inspe pr' t grout) g and a final inspection. <br /> Signed X� r�w itle:- Date: 9 <br /> LT {Draw Plo Ian on Reverse Side) <br /> FO EPARTM T USE ONLY <br /> PHASE IZ �q <br /> Application Accepted By <br /> �97 Date `f / <br /> Additional Comments: of <br /> Phase 11 Grout Inspection L3tLase 111 f=inal Inspection <br /> Inspection By Datte� Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Ica PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> oz/ 9A,? <br /> Received by Date Receipt No. Permit No f Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> A <br />