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Applications Will Be ProcessedWhenSubmittedPropeny Ivompiezea.ae oure 10 atgn ITIV.,�,Nr.a ., • <br /> - FFICE USE: _ APPLICATION <br /> ,. (For Non-Transferable, Revocable, Suspendable) <br /> - <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 instal I the work herein described.This application i s C <br /> made in compliance wi h San Joaquin County Ordinance No. 1862 and the ruleg and regulations of the San,loaqul Local Health District. � <br /> Exact Site Address City/Town ��j 1� <br /> Owner's Name <br /> Phone 1' V <br /> Address - City 60 <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �iii — No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 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 (306 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 0 INDUSTRIAL X.CABLE TOOL Dia. of Well Excavation ti] <br /> ya,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Cn <br /> C1DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing 3 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Or Seal 0 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9S I& <br /> ❑ DISPOSAL ❑ OTHER Other Information t <br /> ❑ GEOPHYSICAL Surface Seal Installed By: m <br /> c f" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P.—L <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 LX <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 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 c I for a Grout Inspection prior to-grouting and a final inspection. <br /> Signed X Title: 94P Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE II� <br /> Application Accepted B Date—t - <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection J�Z_ <br /> Inspection ByDate /� 'f� Inspection By Date �– <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATJON— '_BILLING ~REMITTANCE $ AMOUNTDUE CHECKED <br /> r' DATE DATE REMITTED AMOUNT _ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date _Receipt No, Permit o. Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO ,CA 95201 <br />