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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> Cz W+ (For Non-Transferible,`Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 'f(p��LcQ - G-rfLvn/�P—� WATER QUALITY ? ` �r00 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit F1 San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address s° ' a-;ai .�+s' r its 6 5V-66J,1 4ke� _ City/Town <br /> _ O ;i- <br /> Owner's Name t' *wol. - Phone <br /> Address t City ' <br /> Contractor's Name License# /93 71w4rrBusiness Phone �'F <br /> rtt <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes._ No <br /> TYPE OF WORK (CHECK)---NEW WELL[D- DEEPEN ❑ RECONDITION❑- - DESTRUCTION© - =/ <br /> WELL CHLORINATION ET, WELL ABANDONMENT 1:1 OTHER 13 PUMP INSTALLATION U PUMP REPAIR® CC <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED DiA. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 1 -4 ❑ DRIVEN Gauge of Casing <br /> P9 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: ry Contractor <br /> Type of Pump U H.P. <br /> PUMP REPLACEMENT:_ © State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: f Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t ' <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 fallowing:"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 if call for a Grout Inspection pribr to-9 .utirig and a final inspection. <br /> Signed X a Title: ` Date: f ' <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I OE <br /> Application Accepted By 1 , lS2M�. Date --- <br /> Additional Comments: <br /> _ t <br /> Phase II Grout Inspection tolg' al Ins ection <br /> Inspection By rsrN Date Inspection Date <br /> i <br /> S <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Zeceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATIONBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 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 No. - I suanq_Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOCKTON,CA 952D1 <br />