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__• ++pfruoarevna nqoe rrweaaaV rrncn auuruirteV ruNeny yvu�nCrev. oC..7u�a IV a� et�i rre M r " <br /> FDR OFFICE USE: `� NIh aauuu. <br /> APPLICATION <br /> (For Non-Transferable, <br /> Revocable, Suspendable <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT -J <br /> (COMPLETE iN:TRIPLICATE) WATER QUALITY <br /> AppllcatlonisherebymadetotheSanJoaquin Local Health District for.apermittoconstruct and/or fns#all,thewo�� � X <br /> made,tn compliance with San Joaquin.County rdinance No. 1 62.and the rules an. r ulations of.the San"Jo um Local T I application is <br /> Exact Site Address q eal#h C71 tri <br /> Ict. .,. <br /> City/ToWn <br /> Owner's ame <br /> Addre Phone <br /> r " ContractorCity <br /> — <br /> Contractor's <br /> Name t� � .License �. <br /> Contractor's AddressBusiness-Phone , 3 <br /> Y <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> -- _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ "DESTRUCTION❑ <br /> WELL::CHLORINATION ❑ WELL ABANDONMENT ❑ " OTHER ❑ PUMP INSTALLATION 0 PUMP REPAIR <br /> REPLACEMENT O <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage.Disposal Field Cesspool/seepage Pit <br /> er <br /> Property Line Piivate Domestic Well Public homes#icM1 ,INTENDED USE ':TYPE Of"WELL: <br /> ❑ INDUSTRIAL. ❑ CABLE TOOL" Dia. of Well Excavation <br /> 11DOMESTIC/PRIVATE '❑ DRILLED' " <br /> Dia. ofWell Casing <br /> ❑ DOMESTIC/PUBLIC ❑'DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL-"PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY- _1 ilio <br /> Type of Grout <br /> ❑ DISPOSAL. ❑ OTHER Other Information <br /> 13 GEOPHYSICAL <br /> PUMP INSTALLATION: cto Surf" e Seal Install By: <br /> Contra13 <br /> a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 11 State Work Done: <br /> PUMP REPAIR: ❑ State Work.Done <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth _ <br /> Describe'Material and Procedure <br /> i <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 owneroratcensedagent'ssignaturecertifiesthefollowing:"I certify thatinthe performance ofthe work for whichthispermit . <br /> is issued, I shall-not employ any person.in such manner as to.become subject to workman's compensation laws of California.". <br /> Coritractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work for wh ich this <br /> perm' 1 Issued,;t shall employ persons su ject to rkman's comps n 'tion laws of California.". <br /> 1' <br /> w1d CII fora G�Jcon pri t outing d a"final insp o <br /> Signed X Title:. <br /> Date: { <br /> (Draw lot Plan on'Reverse Side) <br /> FO DEPA TMENT.USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: Date I <br /> Phase IFGrout Inspection Phase lil Final Inspection <br /> Inspection.By Date <br /> . inspection By Date <br /> Fee IS Dile: © ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACH ❑ January 1&Received By',January31 :❑,July:1,&.Received"By.Jufy3i <br /> BASE EXPLANATION 81LLINGREMITTANCE $ - REMIT <br /> DATE DATE REMITTED <br /> AMOUNT DUECHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORAT!O? <br /> PLUS <br /> PENALTY <br /> E <br /> x <br /> OTHE9 <br /> 1. I <br /> OTHER <br /> _ F <br /> -1"o ? <br /> Received"by pate I <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> • APPLICANT—RETURN ALL-COPIES TO:- "ENVIRONMENTAL HEALTH PERMIT/SERVICES - - ,1601 E.HAZELTON AVE.,P.O.Box 2009-_ --STOCKTON,cA$52011 - <br />