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•• �a.RRraerrocessedWhen Submitted Properly Completed. Be Sure To Sign The Application, <br /> 0Fr-ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) s <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYr <br /> Application is hereby made to the San Joaquin Local Health District fora permit toco construct and/or instal)the work herein de�ibe <br /> made in compliance with San Joaquin County Ordinance No. 1862 <br /> Exact Site Address [? and the rules and regulations of the San Joaquin Local Health District. <br /> bed.This application is <br /> Owner's Name S moss- r City/Town C ` <br /> �" O C ` , <br /> Address �I �:l�„ �, Phone r�(p w Q 2— <br /> Contractor's Name 1 �1 r City <br /> Contractor's Address p L/ C� License#33t1�7L Business Phone .5 <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W th SJLHD? Yes__JK____ No <br /> TYPE OF WORK (CHECK); NEW WELL❑ <br /> WELL CHLORINATION 13DEEPEN 13 RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ �. <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field Sewer Lines Pit Privy <br /> Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> r❑ INDUSTRIAL TYPE OF WELL <br /> XQOMESTIC/PRIVATE ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing <br /> ❑ IRRIGATION ❑ DRIVEN Gauge of Casing <br /> E TION <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> ID CATHODIC PROT <br /> El ❑ ROTARY Type of Grout <br /> C1 GEOPHYSICAL ❑ OTHER Other information <br /> PUMP INSTALLATION, Contractor Surface Seal Installed By: <br /> PUMP REPLACEMENT Type of Pum <br /> "` O'Sfa-fie`Wo-rW CDor "—�"" .P. <br /> PUMP REPAIR: ' � ❑ State Work Done <br /> ELL , <br /> OESTRUCTIOI�`OF W : <br /> 41- Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ,,I`/h'�eby ce tify that i have prepared this application and that the woAwill be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> `Home owns or licensed agent's signature certifies the following: y <br /> is Issued, I �phall not employ any person in such manner as to become that <br /> o won the ekman'sncompensatiance of thework f laws of Cal terra permit <br /> zz1z Contract -1 or sub-contracting signs#urs certifies the following:"I certif hat in the 's c <br /> • permit is i shed, I shall employ persons subject to workman's compensation laves of California."ance of the work forwhich this <br /> �! will I <br /> rout spect' rior 10 grouting and a final inspection. <br /> Signed')( <br /> Title: <br /> I'w (Draw Plat Plan on Reverse Side) Date: <br /> PHASE FOR DEPARTMENT USE ONLY <br /> Application Accepted By �-_ <br /> Additional Gomm nts: Date <br /> } Phase I! Grout Inspection <br /> Inspection By Phase III Final Inspection s <br /> Date Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA H <br /> C+ �� El 1 &,R cis elved By January 31 <br /> El July 1 &R <br /> ., - Y By July 31 + <br /> -+,BASE,_ EXPLANATION^-v 5„­3IIBILLING'AN I !REMITTANCE $ REMIT <br /> --DATE_ "'DATE REMfTTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS f r% <br /> PRORATION <br /> PLUS <br /> PENALTY rf <br /> OTHER [ <br /> OTHER r <br /> Received by DateIf <br /> Receipt No. Permit NO. <br /> `APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 957 <br />