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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />� A - <br /> ,FSR OFFICE USE: i; APPLICATION '• �' _ � <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP <br /> WELL { <br /> - ENVIRONMENTAL"HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework 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 Local Health District. j <br /> Exact Site Address L- d City/Town <br /> "1014 <br /> Owner's Name Phone <br /> Address ! c City <br /> Contractor's Name +� Licens@� J Busines Phone �[ I <br /> Contractor's Addres mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Z____ No <br /> TYPE OF WORK (CHECK): NEW WELL IT DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER•1❑ -PUMP INSTALLATION ❑ PUMP REPAIR 1:1REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank ��f 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 t` <br /> E] INDUSTRIAL C1 CABLE TOOL Dia. of Well Excavation �i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of WeII Casing <br /> ❑ DOMESTIC/PUBLIC ± ❑ DRIVEN Gauge of Casing 7,2 <br /> 11 IRRIGATION <br /> ❑ GRDepth of Grout Seal <br /> ' {l, t �1� �� <br /> El CATHODIC PROTECTION i—H�-AVEL PACK UTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL xr Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> ..r H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: r ❑ State Work Done rw <br /> DESTRUCTION OF WELL: Well Diameter, ti 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 />€ Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> k 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 /> permif is issued, I shall employ persons'subject to workman's compensation laws of California." <br /> C� 'r <br /> I will call r a ut Inspection prior to groutin and a sinal inspection. <br /> Signed X - Title: Date: Q i <br /> (Draw Plot Plan on Reverse Side) _J <br /> FOR EPART ENT USE ONLY ! <br /> i <br /> f PHASE I I �� <br /> -. Date <br /> Application Accepted By i <br /> ) <br /> Additional Comments: <br /> I Ph �1111 eclion tae II Final �inve.ti.nQ ��}}inspection By Dated inspection By ` !r <br /> Fee Is Due: ❑ ANNUALLY PER UNIT 9-PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> k EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> }E Received by Date Receipt No. Permit No. - suanc nate Mailed Delivered <br /> STOCKTON,CA 95207 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />