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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> _FOIA,OFFICE USE: APPLICATION 11 <br /> (For Non-Transferable, Revocable, Suspendable) --0 <br /> PUMP&WELL ) <br /> ENVIRONMENTAL HEALTH PERMIT k <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 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 Joaquin Local Health District. <br /> Exact Site Address <br /> City/Town <br /> Owner's Name o Phone z- — I I <br /> Address Z- City <br /> Contractor's Name Business Phone4�G�K <br /> Contracfor's Address�/f`L.yd %iF�rnergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_ �6t a Pit Privy ; <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Linea Private Domestic Well SCI-7- rr 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 i <br /> ❑ D? IC/PUBLIC El DRIVEN Gauge of Casing 1JI <br /> 10 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information -C <br /> ❑ GEOPHYSICAL / Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I® /��e,el,� <br /> Type of Pump H.P. 'Sr <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Eg-State Work Done o <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 performanceof 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 /> permit is issued, I shall employ persons subject to workman's compensation lawspf California." <br /> 1 wi I call for a Grout Inspecti n p ' r to grouting and a final inspecti <br /> Signed X <br /> Title- Date: <br /> (Draw Plot Plan on everse Side) <br /> FOR D ARTM T USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase I I Final Inspection <br /> Inspection By- 406 Date Inspection lay , Date <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> rt r BILLING REMITTANCE $ UNIT DUE CHECKED <br /> BASE EXPLANATION D E DATE REMITTED <br /> AMOUNT <br /> !, FEE 9L^ <br /> I \ <br /> LESS .' <br /> PRORATION <br /> PLUS <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 PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 /fJ <br />