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Applications Will Be Processed WhenSubmittedProperly Completed. Be Sure To Sign The Application. JI <br /> FOR OFFICE USE: I� APPLICATIONi <br /> i� (For Non-Transferable, Revocable, Suspendable) { <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 Sarna Joaquin(County girdinance No. 1%62 and the rules and reaulations of the San Joaquin Local Health District. <br /> Exact Site Address v��`Y � � _ City/Town <br /> ih <br /> Owner' lame II Phone <br /> Addre City <br /> Contractor's Name >L- ���CU�cense Business Phone Z! Y <br /> Contractor's Address 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❑ DESTRUCTION❑ [[[ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ I� r <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 /> I <br /> INTENDED USE TYPE OF WELL n <br /> I ❑ INDUSTRIAL i ❑ CABLE TOOL Dia. of Well Excavation ►� " j <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Toil <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL g <br /> Surf a Seal Il By: ' <br /> PUMP INSTALLATION: Contracto L. f 3 e <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I Its, <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> hDescribe Material and Procedure <br /> i <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." 10 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> perm' is issued, i shall employ persons su ject to rkman's compen tion laws of California." <br /> I w' c II for a Gro lDsppec�'on pri t outing nd a final insp o a <br /> Signed X �"� Title: Date: 7/7 <br /> (Draw lot Plan on Reverse Side) <br /> k it <br /> FO DEPA TMENT USE ONLY <br /> l PHASE I It <br /> Application Accepted By Date <br /> I I. <br /> Additional Comments: I <br /> Phase It Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection <br /> 11 1 <br /> Fee Is Due: ❑ ANNUALLY I� ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BAS E+ EXPLANATION PATE GATE REMITTED AMOUNT DUE CHECKED <br /> I AMOUNT <br /> FEE �!; <br /> y� <br /> LESS 6, <br /> PROl II <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I, -7 e-4 x C39 <br /> F 'Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Boa 2609 STOCKTON,CA 95201 <br /> i <br />