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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspehdable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL y <br /> (COMPLETE IN TRIPLICATE) .I. 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 applicatiA is <br /> i made in p ompliance with Sa Joaquin County Ordinance No. 1862 arm the'r�es nd regulations of the San Joaquin Local Health District, <br /> Exact Site Address L�(�7`3� /da �e�. f�Qrf City/Town 1 <br /> Owner'a?Name ,tax, Phone ' <br /> Address — City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone `52►271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank lee Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other } <br /> Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 OTHER Other Information <br /> ❑ GEOPHYSICAL surface Sea! Installed By: <br /> PUMP INSTALLATION: �� Contractor t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: �I Well Diameter Approximate Depth <br /> E is Describe Material and Procedure <br /> 11 J. <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 /> 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." `l <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 /> Ir <br /> I will ll for a Grout sped' n prior to gr uting and a final inspection. <br /> Signed X 120 Title: Date: / e <br /> i� (JWaw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY E <br /> PHASE I � An� p <br /> Application Accepted By `-"' Date <br /> Additional Comments: IM <br /> P e I rout I spectiorr7 Phase III Final Inpype�c-tiro <br /> Inspection Byf� Date Inspection By �lJ....._._ Date <br /> J <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceNed By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 44a 0%7 <br /> Ip ' <br /> LESS I� <br /> PRORATION <br /> - i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> II <br /> -i: <br /> Received by - Date`fi' Receipt No. Permit No. Issuance Date Mailed Delivered <br /> P ll <br /> APPLICANT—RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />