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Applications Will Be Processed When Submitted erly Completed:Be Sure To SignTheAPPlicalion. <br /> APP <br /> FOR OFFICE USE: ` <br /> APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) ! PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT (/ <br /> (COMPLETE IN TRIPLICATE) ^ WATER QUALITY f�,3,--2,((a-(.3 r <br /> AJE <br /> Application is hereby made to the SanfoaquinLocalHealthDistrictforapermittoconstructand/orinstalithework herein described.This application is <br /> made in compliance wi h San Joag6ul?CQ un y Ordinance No. 1862 and the rules and r ulations of the San Joaquin Local Health District. <br /> Exact Site Address /, d' tc.�a fa. �aMe City/Town <br /> �S'4 Phone <br /> Owner's Name ' � d <br /> l p >=. . a�,.s f �/S ►� City <br /> Address ,r,y ����-0 <br /> Contractor's Name D License#��4� Business Phone' <br /> Contractor's Address ✓ kv Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 USETYPE OF WELL <br /> C1INDUSTRIAL = ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN r Gauge of Casing <br /> I& IRRIGATION « ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Cr <br /> ❑ GEOPHYSICAL. i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Y State-Woik Done a <br /> DE=STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 laws of California." <br /> E <br /> 1 will call for a Grout Inspectio r gro Ing and inal insp tion. <br /> Signed X CS; <br /> lit <br /> w e: Date: <br /> (Draw Plot an on Reverse Side) <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By - <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase 111 Final Inction 7 <br /> Inspection By <br /> Date Inspection By, 6 Date. <br /> I tBy <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. " -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 S ReceivedREMITuIy 31 <br /> ' <br /> _� BILLING REMITTANCE. - <br /> EXPLANATION AMOUNT DUE CHECKED <br /> BASE <br /> DATE DATE REMITTE AMOUNT <br /> FEE I <br /> LESS ' <br /> PRORATION r ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> + <br /> OTHER <br /> Received by � Date: - -_ Receipt No. � Permit No � -� <br /> Iss rice Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />