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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application <br /> FOR OFFICE USE: APPLICATION <br /> 6 )& _Q (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL <br /> rJL ENVIRONMENTAL HEALTH PERMIT I !� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance.No. 18_62 and the rules and regulations of the San Joaquin Local Health District. , <br /> Exact Site Address G& a n 1g./a City/Town <br /> Owner's Name + Phone <br /> Address A—"—, City �t <br /> Contractor's Name License# /f ��S Business Phone L`7L Cy i <br /> Contractor's Address .... A _wow Emergency"Phone ,0 <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No , <br /> TYPE OF WOR K.(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _. <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ f�1 <br /> REPLACEMENT❑ a <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 Q <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I5 IRRIGATION 4❑ 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 f <br /> Type of Pump .. .. e/� hit H.P. .! 441 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP RIS JR State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxim to Depth <br /> Describe Material and Procedure <br /> _41 I hereby certify that I have prepared this application acid 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 /> Homeowner 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 become subject to workman's compensation Jaws 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, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call fora;Grout Inspectlon rib?to' -ting nd a,flnal inspection. <br /> Signed I• 1V Itle: Date: <br /> s <br /> ( '(Draw`Plot= Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date - <br /> Application Accepted By <br /> Additional Comments: t <br /> Phase li Grout Inspection ase III Final In action <br /> Inspection By Date Inspection By Date S"�� , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAGH' ❑ January 1 &Received By January 31 ❑ July S &Received By July 31 <br /> REMIT <br /> BILLING` REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> i <br /> FEE �� d <br /> LESS i` s <br /> PRORATION <br /> PLUS <br /> PENALTY- - - <br /> OTHER <br /> OTHER <br /> Received by - Date - Receipt No. - Permit No. Issuan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />