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Applications Will Be ProceSSUWhen Submitted Properly Completed. Be Sure To Sign a pp ca on. <br /> FOR oFFicE USE: <br /> APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> zZ <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> WATER QUALITY <br /> (C0. PLETE IN TRIPLICATE) a j <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the.work_hereindescribed.This applic I� <br /> . s <br /> made incompliance with San Joaquin County Ordinan a No.1 62 and the rules and regulations of the San Jo uin Local Health District. <br /> p City/Town <br /> Exact Site Address r Q B �? f � <br /> Phone <br /> Owner's Nameil�L S�4-- - -- - City <br /> Address ,: ;f . <br /> - License#?7'7„ _/_� S� Business Phoriet'� <br /> Contractor's Name <br /> Contractor's Address f• Emergency Phone <br /> No . <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— (� <br /> TYPE OF WORK (CHECK):�_NEW'WELL❑ DEEPEN RECONDITION;- DESTRUCTION❑ <br /> WELL CHLORINATION 13 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 /> i INTENDED USE I TYPE OF WELL V 't 1 <br /> 11 INDUSTRIAL ,CABLE TOOL Dia. of Well Excavation <br /> El DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> rr f <br /> 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Ca- 0 ,. <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other, information <br /> — <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> r _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: a ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> rDescribe Material and Procedure <br /> 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 /> f Home owner or licensed agent's signature certifies the following:"]certify that in the performance of thg 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 orsub-contracting signature certifies the following:"I certify that in the performance of thework forwhich this �. <br /> Perm-it is issued, I shall employ pe ons subject to workman's compensation laws of California." - <br /> I w If ora ou spec an rior to grouting and a final inspection. <br /> Title: Date: <br /> Signed X ' <br /> (Draw Plot Plan on Reve a Side) <br /> I FOR DEPARTMENT USE ONLY Cj <br /> PHASE I pa <br /> - x ) (J <br /> Application Accepted By , <br /> l' Dat <br /> Additional Comments: _ <br /> Phase 11 Grout Inspection 11 Final Inspection <br /> ` <br /> }_ Inspection B _Date <br /> Inspection By pate <br /> It <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITd By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> * BASE t EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> ' OTHER • - - _ - . <br /> <J <br /> - <br /> elivered Received by � �- <br /> -Date• Receipt No. '- —Permit No. .- Issua ice ate - Mailed- , <br /> APPLICANT-RETURN ALL COPIES TO:� ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1801 E.HAXELTON AVE.,AYEP.O.90x 2009 STOCKTONCA 95201 <br />