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Applications Will Be Processed When Submitted Propea re I <br /> APPLIQ _MN <br /> _AI ' <br /> FOR OFFICE USE: Stt �(id�le)ig9 J <br /> it (For Non-Transferable, Revocable, PUMP&WELL <br /> ENVIRONMENTAL HE4;r,, P MIT <br /> CIJ U IN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER Ql1AL1TYf L-1-iLTH D; � ��� <br />[ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ins alihe rkhereindescribed.Thisapplicationis � <br /> made in compliance wit en Jo_a�uin C,�[Rity r ange o. 1 62 ar�d tai a rules and regulations of the San J 70 Locral 11 t Dis rict. <br /> Exact Site Address �-� �7 City/Town 1 C1JC/ <br /> 711 Z2 0 <br /> Phone <br /> Owner's Nam <br /> t�n�� City <br /> Address <br /> Contractor's Name 'T u License# Business Phon <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 0 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ now <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11PUMP REPAIR�� <br /> F REPLACEMENT❑ <br /> i' DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> l _ -Sewage Disposal-Field. — Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> 5 INTENDED USE TYPE OF WELL JC <br /> ❑ INDUSTRIAL ❑ GABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ;Wi <br /> ❑ DOMESTICIPUBLIC ❑ 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: <br /> 13 State Work Done t <br /> PUMP REPAIR: EI-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 11 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this g <br /> 1 per Is is d, I shall employ p s subject to workman's compensation laws of California." <br /> E I i r r Inspectio prior o grouting and a final inspec _ / ✓J <br /> Signed X _ <br /> -� Titie: Date: �J <br /> (Draw Plot Plano Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By17 <br /> Additional Comments: <br /> t <br /> Phase II Grout Inspection Phase UI Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rece'ry By REMI July 31 <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I - DATE DATE REMITTED7�'�� AMOUNT <br /> j FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r OTHER <br /> OTHER <br /> L 9-tom I -7fl <br /> Received by Date Receipt No, <br /> Permit No. Issuance Date Mailed Delivered <br /> _�;v <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -3601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />