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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY' ; tC �t ,i <br /> Application is hereby made to the San Joaquin Local Health District fora permit toconstructand/or install the work herein described.This application is <br /> made in compliance wi Joa in County-jDxAwance No. 1862 and ej rules and regulations of the San Joaquin Local Health.District. <br /> Exact Site Addressl �� r U lE/ j� <br /> City/Town <br /> Owner's Name 1 t` Phone r Jt <br /> Address 3:: Y: *- .ti ,.. K. .+ e. <,• City <br /> Contractor's Name icense ! f� Business Phone <br /> Contractor's AddressEmergency Phone `=` _i'' , C� <br /> Is Certificate of Workman's Compensation In ra a on Ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): .. NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -PUMP,INSTALLATION ©' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: -"Septic Tank' Y ' ' 't Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE _ TYPE OF WELL <br /> © <br /> INDUSTRIAL ❑ CABLE_TOOL Dia. of Well Excavation Z/�z/,4 <br /> U-01 MESTIC/PRIVATE -`� 0"[�RILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 9-TrOTARY Type of Grout L <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface S al,In ailed By: / ' <br /> PUMP INSTALLATION: Contractor r �� <br /> Type of Pump I 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 /> 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 /> r 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 ca I a Gr prior to grouting and a final inspection. <br /> Signed Title: J �Y C- 'l/.. Date: S <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY e <br /> PHASE I <br /> Application Accepted By - - Date <br /> Additional Comments: } <br /> hase 11 Groutspection Phase III Final Inspection <br /> Inspection-By *1 Date I-, .. _ Inspection By <br /> Fee Is Due: ❑ ANNUALLY _E PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By JarivaFy 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $� w .r- �. 0-0 <br /> t <br /> LESS ' _ <br /> PRORATION <br /> PLUS u R <br /> PENALTY - <br /> r <br /> OTHER <br /> I <br /> OTHER <br /> Received by Date - Receipt No •--- - -Permit No. su ce Date Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />