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__ Appiicat.ions Will Be Processed When Submitted Properly Completed BeSureTosign IneRppncaiion. <br /> /J�F�CIF:R-OFFICE USE: APPLICATION , i <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WALL <br /> Cam 7 <br /> l ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the-San Joaquin Local Health District for a permit to construct and/or install the work herein described.This applicatio <br /> made in compliance with San Joaquin County.Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> � Cit /"town O <br /> Exact Site Address_,3_4572 3 �A 1804 -P� City <br /> /Town <br /> Name / + ' Phone J <br /> Address City <br /> Contractor's Name �- License#_rr/ ^'7]d Business Phone 2 `76 <br />' Contractor's Address __ .rL Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S LHD? Yes—X 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 FieldCesspool/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 /> 1:1DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat N <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> j <br /> 1:1 DISPOSAL 1:1 OTHER Other Information <br /> j ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractor <br /> 'Type of Pump �+ H.P. A <br /> I PUMP REPLACEMENT: 10 State Work Done A7-K I-r-e AW A4i <br /> I " <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> f <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:1 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 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 fpr 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 Pr or 10 r utln`and a sinal inspection. <br /> 'y) <br /> Signed <br /> �Plotlan <br /> : / Date: <br /> (Drawn Reverse Side) <br /> -------------- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: I - <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By IiTf Date Inspection By Date <br /> d By <br /> Fee Is Due: 13ANNUALLY ElPER UNIT ElPER SITE ❑ EACH ❑ January 1 8 Received By January 31 El July 1 &ReceiveREMITuIy 31 <br /> - _ BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> f <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �! <br /> OTHER <br /> OTHER <br /> ,- 7c7W <br /> Received by <br /> Date Receipt No Permit No. uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9529,1_ <br />