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ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. {{ <br /> FOR OFFICE USE: APPLICATIONJ. <br /> J <br /> (For Non-Transferable, Revocable, Suspendable) s' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL { <br /> U} <br /> {COMPLETE IN TRIPLICATE)' WATER QUALITY lS� <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 Joaqui Cou ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address n� �f � � ,�„ g�_yp/� Cef <br /> City/Town <br /> Owner's Name Phone g9Z7 <br /> Address _�• �(2. �. _L r _._ City <br /> Contractor's Name License# Business Phone ,L <br /> Contractor's Address , Emergency Phone L9 11142 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 10 <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 PROTECTIONQ <br /> 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. 57� <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: ❑ State Work Done <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 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 In If It prior to grouting and a final inspection. <br /> Signed X Title: / P- <br /> Date . <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted Bye��Iy <br /> Q" 6 Date 7 <br /> Additional Comments: <br /> Phase 11 Grout Inspection base III Final Inspection �} <br /> inspection By Date Inspection By � T Date <br /> Fee Is Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> $ <br /> BASE EXPLANATION <br /> BILLING REMITTANCE REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 0 <br />