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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sig The he Application. W' <br /> FOR OFFICE USE: ��, APPLICATION �� v <br /> (For� Non-Transferable, Revocable, Suspendable) 1 l f <br /> II ENVIRONMENTAL HEALTH PERMIT 9 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora perm it to construct and/orinstalIthe work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rules and regulations of the San JoaquinLoc I Health District. <br /> I Exact Site Address �5' c <br /> City/Town .a fDc/"l ! <br /> II <br /> Owner's Name � .� Phone <br /> Address _ .Q _ City <br /> Contractor's Name A, License# Business Phone <br /> f Contractor's Address Emergency Phone <br /> is Certificate of Workman's;Compensation Ins ance 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 REPA IR❑ i <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST:I� Septic Tank Sewer Lines Pit Privy <br /> E Sewage Disposal Field <br /> Cesspool/Seepage PitOtherf � i <br /> ,/ f Al <br /> T ` Property Line IS',' Private Domestic Well Public Domestic Well <br /> /1IVTENDED USE I! TYPE OF WELL <br /> INDUSTRIAL ii ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE °'i ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC l� ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION II GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type 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 f� <br /> PUMP REPAIR: n ❑ State Work Done <br /> DESTRUCTION OF WELL:�� Well Diameter Approximate Depth <br /> :f 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 /> r 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 for which this permit <br /> is issued, I shall'not employ any person in such manner as to became 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 for which this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. ` <br /> Signed XN <br /> Title: ` Date: <br /> (Draw Plot Plan on Reverse Side) <br /> { FOR DEPARTMENT USE ONLY <br /> PHASEI ; <br /> Application Accepted By CQDate_ `-9— .. R <br /> Additional Comments': <br /> I!Phase II Grout Inspection Ph�se�ll F I Inspection <br /> Inspection By Date Inspection Sy ��� Date <br /> n , <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv d By January 1-[] July 1 E,Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> :BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE, DATE REMITTED AMOUNT <br /> FEE <br /> LESS II <br /> PRORATION I� - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER q <br /> t <br /> 1 q��-i I <br /> Received by II Date Receipt No. Permit No. f Iss ance Date Mailed Delivered <br /> APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />