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Applications Will Be Processed When Submitted ProperlyCompleted. Be SureToSign 1neAppnca Ion. <br /> FOR OFFICE USE: APPLICATION <br /> _.�. (10ixP114�ik (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> I ENVIRONMENTAL HEALTH PERMIT l <br /> (COMPLETE IN TRIPLICATE r <br /> ,� ¢ EWATER QUALITY }yQyJ j e15-- '�0'0 <br /> �Appl icat ion is hereby made to the San Joaquin Local HeaI th District for a permit to construct and/or install the work herein described,Th i s appl ication is <br /> EEE made in compliance with San Joaquin Coun y Ordinance No. 1862 and th rules and reg of the San Joaquin Local Health District. <br /> Exact Site Address atC SomA " p�,. City/Town <br /> k Owner's Name S Phone <br /> Address City <br /> Contractor's Name _ License Business Phone Y"' 71;76 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on �Wftth D? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 4 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic WeII Public Domestic Well <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 /> l� IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> k <br /> ❑ DISPOSAL ' ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> k � M1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. SO <br /> PUMP REPLACEMENT: 0 State Work Done <br /> f PUMP REPAIR: <br /> L�state Work Done <br /> i <br /> DESTRUCTION OF WELL: f Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 11 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. C <br /> Homeowner Or licensed agent's signature certifies the following:A 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 /> I 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 /> II will call for a Grout Inspection ri too ing and final inspection. <br /> Signed 1M+° itte: _ _ Date: <br /> (Draw Plot an on Reverse Side) <br /> f _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ate <br /> Additional Comments: <br /> Phase II Grout Inspection P se III Final Inspection <br /> Inspection By Date Inspection By Date . <br /> k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec wed By January 31 ❑ July 1 &Received By'July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ \` A�JIQUNT DUE CHECKED <br /> DATE DATE ITTED AMOUNT <br /> X. / <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER <br /> Received by Date Receipt No. Per iit No - Issuance Date Mailed Delivered <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,.CA 952D1 <br />