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Applications WIII 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 -7 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installthework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town �^ <br /> Owner's-Name '' <br /> Phor <br /> Address 'c-^"._ate. r City <br /> Contractor's Name �� n� _ " � License 464. _ Business Phone i35 <br /> t <br /> Contractor's Address Emergency Phone <br /> 1s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes may"~� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN,❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION 6 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy W <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line . Private Domestic Well Public Domestic Well <br /> JNDED USE TYPE OF WELL <br /> L`f IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 /> t ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �S 45 <br /> Type of Pump_,� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I 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 /> 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for aGrout Insp ction prior to grouting and a final Inspection. <br /> Signed - t low` Jitle:,—I� -�.L�_ Date: <br /> (Draw Plat Plan on.Rev rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> �PHASEI <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Ph in Inspection <br /> A <br /> Inspection By Date Inspection By e , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 3i ❑ July 1 &Received 8y July 3i <br /> ' REMIT <br /> e EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> Received tY Date Receipt No. <br /> Permit No. Issuance Date Mailed Delivered _ <br /> 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOGKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />