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Appiicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION �yL <br /> (For Non-Transferable, Revocable, Suspendable) <br /> x ` v _ ENVIRONMENTAL HEALTH PERMIT PUMP&jNELL"�= <br /> (COMPLC-TE IN TRIPLICATE) WATER QUALITY ` <br /> ` `.,, _ <br /> Application is hereby made to the San Joaquin Local Health District for a permitfo construct and/or install the work herein described.This a ion is <br /> made In cogrtpliance with San Joaquin County Ordinan! o. 1862 and-the rules and regulations of th San J aquin Local Heal strict, <br /> Exact Siteddress 174111 Lf. <br /> n <br /> Owner's Name Phone A35 75,E + F <br /> Address , City lL_ <br /> Contractor' 1�7s Name License# / Business Phone — <br /> Contractor's Address S Emergency Phone -^Oa 7 <br /> Is Certificate of Workman's Compensationfns rance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 170 Sewer Lines Pit Privy <br /> Sewage Disposal Field /7-0 / Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well <br /> 1= Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED '/ <br /> r� Dia. of Well Casing <br /> V DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1A2 wCdY=t,, . <br /> IRRIGATION X GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION y+s ROTARY Type of Grout <br /> CI-DISPOSAL ❑ OTHER Other Information <br /> J3 GEOPHYSICAL Surface Seal Installed By; t. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. }� <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 /> 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all fora Grout- sped- n prior to grouting and a final inspection. <br /> Signed X e: ` <br /> � Date: <br /> (Draw Plot non Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br /> 4� <br /> PHASE.I <br /> Application Accepted B Date <br /> Additional Comments: h <br /> P rout Inspection / Phase III Final Inspection r <br /> Inspection B Date spectio By Date <br /> . Fee IS DU@: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> -BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE a �0� / ------ <br /> LESS <br /> 1LESS ' ! <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Received by Date Receipt No 15eFmitNo- -Issuance ate Mailed - Delivered F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />