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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTHIPERMIT �d ���� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct andlor 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 �o �� ' <br /> City/'Town G ' <br /> m f� <br /> Owner's Name c �,r l!�> t'fd� Phone o, I <br /> Address ^-� r <br /> City , <br /> Contractor's Name IL�T' �;^ ' �' ,�„LicenselBusiness Phonet�� ` <br /> Contractor's Address Emergency Phone 'o.; - n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEWWELL❑ DEEPEN ❑ PRECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONPUMP REPAIR❑ <br /> REPLACEMENT❑ QQ <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 /> i� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMLSTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work'Do e <br /> PUMP REPAIR: ❑ State Work Done p <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 CountJV ' <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 permi <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 thi <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.” 1 <br /> I will call fo G out Inspectio prior to grouting and a final inspection. <br /> c <br /> Signed X Title: ��su}^t.E-�� Date: -to-2,3 # <br /> (Draw Plot Plan on Reverse Side) <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> ;.Application Accepted By ' <br /> Date <br /> Additional Comments: y <br /> Phase li Grout Inspection f <br /> P inaltnspection <br /> y Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JulyReceived By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY. <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No . .Permit No. - issue ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952011 ,f <br />