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Applications Will Be Processed When Submitted Properly Corrl BeSureToSignTne_Appl + <br /> FOR OFFIZH USE: APPLICATION ' <br /> {For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> {COMPLETE IN TRIPLICATE} <br /> 1 <br /> Application is hereby madetotheSan Joaquin Local Health District for a permit to construct and/or installthe work herein described.This application rs <br /> made in compliance with Sa d guin County Ordinance No. 1862 and the rules and regulations of the San Jo qui cal Health District. <br /> Exact Site Address !� City/Town "}} —� <br /> «.. l <br /> Phone <br /> Owner's N me <br /> City�� _ <br /> Address O� � <br /> Contractor's Name - License# Business Phonelj__.�_:_C� a <br />' ONX <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation'insurance on File With SJLHD? Yes No <br />` TYPE OF WORK (CHECK): "T NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i�� <br /> WELL CHLORINATION 11. .-WELL ABANDONMENT ❑ _ _OTHER ❑ PUMP'INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank AdnD Sewer Lines Pit Privy t <br /> Sewage Disposal Field Cesspool/Seepage Pit /��� j Other <br /> Property Line� Private Do-mestic Well Public Domestic Well <br /> INTENDED-USE "' TYPE OF WELL r �' <br /> 13 INDUSTRIAL CABLE TOOL Dia. of Well Excavation f i <br /> y�+� ❑ DRILLED } Dia. of Well Casing <br /> J�'tJOMESTIC/PRIVATE ..,. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I ❑•IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal d <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL_ ❑ OTHER Other Information + <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Cll <br /> Type of Pump - H.P. <br /> .fir G` <br /> PUMP REPLACEMENT: - ❑ State Work Done ) <br /> ;. PUMP REPAIR: ❑ State Work Done <br /> � Approximate Depth -^ <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> k hereby certify that k 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 owner or licensed agent's Signature certifies the following:"I certify that in the performance of the work for which this permit <br /> .^A W <br /> �,. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> t <br /> i Contractor's hiring or sub contracting signature certifies the following:"l certify that in the performance of the work for which this <br /> permit is issued, 1 shalt employ,persons subject to workman's compensation laws of California." � <br /> I will c II for a Grout Inspection prior to grouting and a final inspection. 1 / •5 <br /> ft Signed X Title: - � aZ Date: <br /> T <br /> t (Draw Plot Plan on Reverse Side) <br /> F R DEPARTME USE ONLY <br /> PHASE <br /> Date <br /> :Application Accepted By <br /> Additional Comments:� - �• <br /> Phas I G 1 Inspection T hose 1 final Inspection <br /> Inspection By ate Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT N PER SITE ❑ EACH ❑ January 1 &Received BY January 31 ❑ July 1 &Receiv By REMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT <br /> 1. <br /> i FEE �O <br /> LESA, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 'OTHER <br /> u <br /> Received by Rate 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 95201 <br />