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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE IISE: APPLICATION <br /> _ (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County eAmance .1862 and tft2 rules and regulations of the San Jo In L rat Health District. <br /> Exact Site Address ,2 City/Town �!( <br /> Owner's Name ,EY +r' to kf S Phone �d <br /> Address G A e)-a ktl>[' 4 A 1n 1" City t>' i <br /> Contractor's Name t A_�P\pr License# Business Phone <br /> Contractor's Address Emergency Phone _ *+ <br /> Is Certificate of Workman's Com0ensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t//„ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ 20 Sewer Lines200 Pit Privy , <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> .Property Line Private Domestic Well J_S�0 Public Domestic Well <br /> INTENDED USE TYPE OF WELL R <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor 0 W pt Pr j ! <br /> Type of Pump - 7(J H.P. <br /> \� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 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 laws of California." <br /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Caiifornia." <br /> I -will <br /> call <br /> �for <br /> �a Grout <br /> Inspection <br /> for to grouting and a final inspection. <br /> Signed X �`�"�"�^t W�� Title: Date: s 4a <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection a III Fin spectio <br /> Inspection By Date Inspection By Date l U <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT L^! PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _M Y-_ �)/ (�, /�6 267 7 'Ti,6 <br /> Received by I Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />