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App licgtlons Will Be Processed When 5Abmitted Properly Completed. Be Sure To Sin The A lication. 1 ".' <br /> .15 <br /> FOR OFFICE USE: c� v � A,PPLICATION g pp <br /> f � <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL I - <br /> ' '� <br /> A! <br /> ° °6NVR�ONMENTAL HEALTH PERMIT <br /> L. I've <br /> (COMPLETE IN TRIPLICATE) HEA ll"�-i DISTRI <br /> CT 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 SanJoaquin Cou=Ordina o. 1862 ppd the rules and regulations of the San'Joaquin Local Health.District. <br /> Exact Site Address '�1 <br /> City/Town C__ Q <br /> Owner's Name , <br /> Phon <br /> Address r City 0 <br /> Contractor's Name iI" + <br /> License# ��"T� (] Business Phone — 14 <br /> Contractor's Address Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r, <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 /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> f L Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL ;I- ❑ 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 I ❑ OTHER Other Infprmation <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ------------------- <br /> Type of Pump L!. Z H P U` <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> 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 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 /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shaJ.1 employ <br /> t rpersons su c to workman's compensation laws of California." - <br /> I will call for a G spection prior t n nd Min Inspect! <br /> t <br /> Signed X � i. Date: <br /> s (Draw Plot Plan on Reverse Side)'�p <br /> FOR DEPARTMENT USE ONLY 4 4 <br /> PHASE I <br /> Application Accepted Ba Date <br /> Additional Comments: I` <br /> F 4 i <br /> Phase II Grout Inspection lase 111 Final Inspection <br /> - Inspection By _ bate <br /> Inspection By. l Date � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31" ❑'July 1 &Received By July 31 <br /> If BILLINGREMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> 'q DATE DATE REMITTED AMOUNT <br /> FEE- <br /> LESS f <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> I c } .. <br /> F <br /> Received by Date Receipt No. "--.. Permit No, Issuance Date Mailed Delivered ��/1'� <br /> APPLICANT•—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201�J <br />