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Applications Will Be ProcessedWhen Submittea NropenyLompleteu. Wu�u•v •W W'"', ^rr•• <br /> Y FOR OFFICE Use: APPLICATION <br /> (Far Non-Transferable, Revocable, Suspendable) pUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> r <br /> `' W TER QUALITY �O/ b7Q_� <br /> (COMPLETE IN TRIPLICATE) WI - S4"_10,' - <br /> ApplicationisherebymadetotheSanJoaquinLocalHealthDistrictforlapermittoconstructand/orinstall the work herein described.Th is application is <br /> made in compliance h San Jaw Cou Ordin c�No. 62 and the rules and regulations of the San oalu�L a lts Djstrict. - <br /> Exact Site Address r [ c� e City/Town / (J /(��J <br /> o�� e, a 7� 17 <br /> Owner's Name Phone <br /> Addrss <br /> City _ <br /> Contr <br /> SIB! <br /> actor's Name w L S Lice <br /> # Business Pione <br /> Contractor's Address QNQW Emergency Phone N <br /> Is Certificate of Workman's Compensation Insu nce on File ith SJLHD? Yes No t <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El PUMP <br /> ❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ <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. l <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ♦ <br /> DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casi6g <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ! <br /> 13 CATHODIC PROTECTION ►ROTARY Type of Grout !� �f1 <br /> ❑ DISPOSAL ❑ OTHER Other Information �. <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 <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 /> r 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 cal for a ut In ion prior to grouting and a final inspection. 27 y <br /> Signed X <br /> Title: Date: r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTME T USE ONLY <br /> PHASE I ?� <br /> Application Accepted By Date <br /> Additional Comments: <br /> as II Grout Inspection Ph a 111 Final Inspec on (� <br /> Inspection By Date Inspection By- ate211 / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 181 PER SITE ❑ EACH ❑ .Sanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 'BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 � <br /> Received ey Date Receipt No, Perrn it No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2409 STOCKTON,CA 95201 <br /> f <br />