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R Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) r PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) 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 San Joaquin County Ordinance No. 1862 and th rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address L1 City/Town <br /> Owner's Name Phone <br /> Address — City <br /> Contractor's Name qwr acs► License#, _f 41 Business Phone <br /> Contractor's Address f , Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�� - No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP iNSTALLATIODI�EZ PUMP REPAIR❑ <br /> REPLACEMENTW <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 2 /5V Pit Privy <br /> Sewage Disposal Field 7 l._:Vf Cesspool/ eepage Pit Otherts/t.�1 _ <br /> .,Vm <br /> S .0.-a4'raperty Line "Private Domestic Well Public Domestic Well e gnT� <br /> INTE DED USE fC TYPE OF WELL / <i <br /> 11 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing �F <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION JJJ �`�GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N- <br /> ❑ DISPOSAL ❑ OTHER Other Information . <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: 49ftLU4 <br /> PUMP INSTALLATION: Contractor +�1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> it <br /> DESTRUCTION OF WELL: Well Diameter Ap o_ximate epth <br /> Describe Material and Procedure <br /> An_'r <br /> k�J � f � f <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a GroutAnspection prior It groutin and a final inspection. <br /> Signed X _ sl Ti11e: >� _ Date: <br /> s (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By `^' ©� Date <br /> Additional Comments: <br /> P a II Graut inspection / ,API�se II Final Inspection ) <br /> Inspection By� ''' Date 14-6- � Inspection By. �v� � w Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ K <br /> BASE EXPLANATION DATE DATE REMITTED 11 AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE at <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 />