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Applications Wfill Ike" rocessed When Submitted Properly Completed. Be S o�r4hi'}Appilcation. <br /> FOftFFICE USE: F - APPLICATION q k979 <br /> (For Non Transferable, Revocable,Suspendable �` UV C�d t <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> S0AQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN TRICT <br /> ,j'rIin its s <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the r ereidescribed.This application is <br /> made in compliance with San Joaquin Cp4rity Ordinance No. 1M_2 a,n the rules and regulations of the San Joaquin Local Heal f�I�tr�� <br /> Exact Site Address �✓�'�"�-L,& City/Town ,S727C7G p <br /> I <br /> Owner's Name 6e;x7_009y a Phone 67zi;l -4�06 <br /> Address ' 7l�rr� City <br /> Contractor's Name, /� v� 4�' License Busine s Ph e <br /> Contractor's Address AjA4 i <br /> a __< <br /> �� Emergency Phone �{ <br /> Is Certificate of Workman's Compens tion rnsurance on File With SJLHD?. Yes� No l <br /> N ' <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r1 f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR' �} , <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 ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY T ` <br /> ype 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: ❑ State Work Done or > <br /> PUMP REPAIR: tate Work Don <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 cer ' that in the performance of the work forwhich this <br /> permit is iss , I shall empl 'rsons subject to workman's compens laws of California." <br /> wr out Inspe ion p for to grouting and a final inspectiplA, <br /> Signed XTitle: Date: Zf f <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date / a <br /> Additional Comments: <br /> Phase II t lspection Phase III F1 Inspection'',, gg^^ QQ <br /> Inspection 8y Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Pr PER SITE' ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMITAMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE !� <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 <br />