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Appncatlons Will BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Susp ndable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 the rules and regulations of the San Joaquin Local Health District. <br /> 170—�. <br /> Exact Site Address =� City/Yawn etO <br /> Owner's Name, � Phone _" Z,. � <br /> Address 40-t' City ,1,+ <br /> Contractor's Name 011veg L License Business Phone r-- <br /> Contractor's Address d O',—Emergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ l n <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ v 1 <br /> REPLACEMENTM— <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 OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ElOTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ce H.P. <br /> PUMP REPLACEMENT: ®-State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. K <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 /> 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 /> I will call for a Grgypt Inspection prior to grouting and a final inspect' n. t <br /> Signed X Title: Date: d <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �"o+► O Dale~"1 <br /> Additional Comments: <br /> Phase 11 Grout Inspection a I Final Inspection <br /> Inspection By NNS a DateInspection Date ` 7 <br /> Fee IS Due: ❑ ANNUALLY- ❑ PER UNIT El PER ISITE ❑ EACH ' ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 •;4 <br /> BASE EXPLANATION BILLING .REMITTANCE $ <br /> REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS y <br /> PENALTY F1 <br /> OTHER I <br /> OTHER <br /> r 1 <br /> Received by Date Receipt No, -Permit No. Iss ante D to Mailed Delivered I: <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 t <br />