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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) „Q <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE} WATER QUALITY <br /> LP <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit Sa Joaquin County Ordinaas±-Nia..166 d the rules and regulations of the San J uin Local ith District. <br /> I Exact Site Address ,/" City/TownIr i <br /> E - <br /> �: <br /> Owner's Name Phone i/ a <br /> Address — City <br /> Contractor's Name License# 7. /t6 Business Phoe I Ile <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensati Insurance on File With SJLHD? Yes— _ No r <br /> TYPE OF WORK (CHECK); NEW WELL 11 DEEPEN 11 RECONDITION u DESTRUCTION❑ t <br /> WELL. CHLORINATION,, WELL ABANDONMENT ❑�OTH RMP INSTALLATION © PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <br /> DISTANCE TO-NEAREST: Septic Tank Sewer Lines Pit Privy �. <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r <br /> Property Line Private Domestic Well Public Domestic Well 21 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL— .-x ❑ CABLE TOOL Dia. of Well Excavation t g <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN . Gauge of Casing ¢J <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �! <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout , <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> S <br /> Type of Pump H.P. ro <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> • f <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this t' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspec' i. J <br /> Signed X Title. Date: <br /> (Draw Plot Plan on R verse Side) <br /> FOR DEPARTMENT USE ONLY d <br /> PHASE I <br /> Application Accepted By ,�-�—a _ Date R ZO � <br /> Additional Comments: <br /> Phase 11 Grout Inspection PhaseI Fin pection f <br /> Inspection By Date Inspection By ate 1 7,1 iao I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Fleceived By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUECHECKED q <br /> AMOUNT AAAf <br /> FEE 1 <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �C+ <br /> r f <br /> "7q---13'71 17 -'74 J <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.Boa 2409, STOCKTON,CA 952 <br />