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FOR OFFICE USE: APPLICATION <br /> For Non-Transferable, Revocable,Suspendable�) ` <br /> /J <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> F(COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal#the work herein described.This application is <br /> made in compliance with San JoaquinCountIt Ordinance No. 1862 and the rules and regulations of the San Joa uin Local 'He`alth District. <br /> Exact Site Address 6 , G irl9 City/Town S cTa+�� <br /> yOwner's Name Phone i q() <br /> Address0600 (5 W Cit, �_ � <br /> Contractor's Name C License#31 � Business Phone__ <br /> Contractor's Address Z+QZ► Emergency Phone •�/-+ <br /> .Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L,� No 1 <br /> TYPE OF WORK (CHECK): NEW WELL[A DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ i, <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Cess ool/SeeSewage Disposal Field a e Plc Other. <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ,❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _____ <br /> ® IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL, Surface Seal Installed By:_. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P_ « <br /> .PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth IL 11 <br /> i` 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 /> k • Home oviner or licensed agent's signature certifies the following:"I certify that in the performanceof.thework for which this'permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's cormpensatioll Laws of Caljfornia." <br /> lCiractor's hen or sub-contracting signature certifies the following:"I certify that in the performance of the worleforwhich this <br /> -isslae , I shall employ ersons ubject to workman's compensation laws of California."I for t Ins i prior to routing and a final Inspection: <br /> { :: <br /> Signed X Titley dIJC tet ] � ate: � <br /> (Draw Plot Plan on Reverse Side) <br /> t� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> , <br /> Application Accepted y Date <br /> Additional Comments. <br /> Phas 11 Grout Inspection Phase III Final Inspection <br /> 1 Inspection By Date Inspection By Date <br /> 111 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> IBILLING REM{TTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - - <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date Receipt No. Permit No, 155 ance Date Mailed Delivered <br />} APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br /> f <br /> f <br />