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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. , <br /> fliR oF�ICE USE: APPLICATION <br /> { (For <br /> Non-Transferable, Revocable,Suspendable) PUMP I <br /> &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is he 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 rdinance No" 1862 and the rules and regulations cf the San aquin Local Health District. <br /> Exact Site Address City/Town <br /> woo <br /> Owner's Name <br /> Phone <br /> Address City — <br /> Contractor's Name AD License#&i323--- Business Phone 3 <br /> Contractor's Address r 1- <br /> -'Emergency Phonetfc� rp— <br /> Is Certificate of Workman's Compensation Insurance cn File With SJLHD? Yes No 1 <br /> TYPE OF WORK(CHECK): NEW WELL❑ _ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR IJREPLACEMENT❑ <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 OFWELL <br /> ❑ INDUSTRFAL '4❑ CABL-E-•TOOL .Dia-of-Well-Excavation <br /> ,QLDOMESTIC/PRIVATE DRILLED Dia" of Well jCasing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN - <br /> Gauge of Ciiing �v*=.• �^f-:... <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Uut Seal <br /> ti ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout ) T r <br /> 11 GEOPHYSICAL ❑ OTHER Other Informati4h + <br /> urface Seal Installed'By-, <br />- PUMP INSTALLATION: Contractor y <br /> Type of Pump ( _P �� -- <br /> PUMP REPLACEMENT: IRState Work Done P. <br /> ` " ti <br /> PU P REPAIR: ❑ State Work Done I <br /> ` <br /> DESTRUCTION OF-WELL:. r, .� Well Diameter <br /> ---- <br /> _ _ f Approximate Depth <br /> Describe Material and Procedure-- <br /> I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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 performanceof the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will II f a Grout Ins ion prior to gr uting and a final inspection. ' <br /> Signed X Ile: ! Date: �� -3— Q <br /> (Draw Plot Plan on Reverse Si e) 0 4N - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r # } ;j <br /> � I <br /> Application Accepted.By I <br /> Additional Comments: t a <br /> Phase II Grout Inspectionhale ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> �. 4 :. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 <br /> t } <br /> ❑ July 1 &Heceived'By July 31 <br /> RASE EXPLANATION BILLING - REMITTANCE $ REMIT <br /> DATEDATE 'REMITTED AMOIfNT DUE CHECKED <br /> 'A- D <br /> FEE FOCI s <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> _ -- 3 D— <br /> Isq4Date Received by Date Receipt No. Permit No. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ✓f` <br />