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Applications Will Be Processed When Submitted Properly Completed. Be Sure o t AlAic <br /> FOR OFFICE USE: APPLICATION t <br /> (For Non-Transferable, Revocable, Susp I <br /> h <` . ENVIRONMENTAL HEALTH PE i98�PUMP&WELL I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District forapermittoconstructand/ori TaJythakvdr�Cf ) jRdeYied.This applic ation is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations Ft.h`fin_ObiliggU�Iocal Health District. <br /> Exact Site Address 1 .C �(.1 7 y <br /> ' City/Town �/ 12?c�0�.,/�.! G <br /> Owner's Name ,aQy u����� Phone <br /> Address _ City �'�Ci f f� � <br /> Contractor's Name Licens ` Business Phone <br /> Contractor's Address � v^ Emergency Phone ,� <br /> Is Certificate of Workman's o s t n 1 1T surance on File With SJLHD? Yes V—' No <br /> TYPE OF WORK (CHECK): NEW WELL Imo—DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�"PUMP REPAIR❑9 <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank ���� � Sewer Lines Pit Privy <br /> N <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> j. <br /> INTENDED USE TYPE OF WELL „ r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> gi=MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /I <br /> ❑ IRRIGATION r ❑��GR-AVEL PACK Depth of Grout Seal <br /> PsSc <br /> ❑ CATHODIC PROTECTION ,� "ROTARY Type of Grout J law, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ` ~ *" Surface Seal nstalled By: <br /> �- a <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMtIAT:_ ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done N <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth N <br /> Describe Material and Procedure <br /> I hereby certify.,ft I have prepared this application and that the work will be done in accordance with San Joaquin County O <br /> ordinances, statI'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 pall for a,Grout Inspection prior to o 'ng and a final inspection. <br /> Signed X 0 ''�'r14.= — Title: Date: T.2 A,� _6 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTME T USE ONLY <br /> PHASE <br /> Application Accepted By 3 Date <br /> Additional Comments: <br /> of hase,11 r Ins ction Ph se III Final Insp ction <br /> Inspection By Inspection B �- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 LJ Jury 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION 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 />