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r Applications Will Be Processed When Submitted Properly Completed.BeSureTosign kneNlppm+--at— <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Translerable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 with San Joaquin County Ordinance-No, 1862-and-the rules and_regulations of the San Joaqui Loc H alth District. <br /> �,F - LY�V_, �. .City/ own <br /> Exact Site s <br /> Addres — - <br /> Phone Jl <br /> Owner's Name e t r.. City HCl <br /> Address <br /> Lidense# Business Phone <br /> Contractor's Nam <br /> Emergency Phone <br /> Contractor's Address Fi e With SJLHD? Yes No O� <br /> Is Certificate of Workman's Compensation Insurance on �� <br /> TYPE OF WORK (CHECI<): NEW WELL❑ _. DEEPEN C3_ RECONDITION 13 ,_DESTRUCTION❑" 1 Qi <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ M1 OTHER 11 PUMP`rINSTALLATION I� PUMP REPAIR❑ <br /> REPLACEMENT❑ k <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit - Other <br /> Property Line Private Domestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIALS <br /> ❑ CABLE TOOL = Dia. of Well Excavation <br /> ❑ t <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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal installed By: ' <br /> ❑ "GEOPHYSICALf. <br /> PUMP INSTALLATION: ContractOIL <br /> Type of Pump — <br /> PUMP REPLACEMENT: T ❑ State Work Done <br /> l PUMP,l : 09 State Work.Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> t 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, l 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 Will call for a Grout I p i pri to uting-an final inspection. <br /> Signed <br /> itle: r A _ Date: I � <br /> (Draw Pio _Ian on Reverse Side) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I 4 i �-'19g,_w Date <br /> Application Accepted By <br /> ',.Additional Comments: <br /> Phase II Grout Inspection ha 111 Final spection <br /> Date <br /> Inspection By. <br /> Date <br /> Inspection .- <br /> Fee I§Due: ❑ ANNUALLY ❑ PFR UNIT - © PER SITE ❑ EACH. ❑ January 1 &Received By Ja ary 31 ❑ July 1 &Recciv <sBy July 31 <br /> REMIT <br /> BILLING REMITTANCE' - $ AMOUNT DUE CHECKED' <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ' FEE �.. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER <br /> f <br /> Date k Receipt No. Permit No. Issuan a Date Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICE5 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTON,CA 95201�r <br />