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Applications Will Be Processed When Submitted Properly Completed. BeSureTo <br /> F % xFo taFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pLIMp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 C u y Ordinal re No. 1 �Id the rules and regulations of the San J m Ligil Health District. <br /> fk Exact Site Address 70 e City/Town <br /> 11 <br /> lvd- LI-el U i- Phoner5� 6 $�S—d7Q o <br /> Owner's Name ,2 City <br /> 0 �� C �,h <br /> Address <br /> Contractor's Name <br /> nse# grZG 4'�Business Phone �G z v l <br /> Contractor's Address e GE r%rgency Phone � <br /> ' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> k C <br /> F TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTAI_LATIONV PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 9 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing `B <br /> IRRIGATION 9 GRAVEL PACK Depth of Grout Seal U <br /> II <br /> ❑ CATHODIC PROTECTION 91ROTARY Type of Grout evh <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfynce,Sea1 Installed By: <br /> PUMP INSTALLATION: Contractor �C "t ` °r'f 7`N�/ <br /> Type of Pump <br /> N",' si t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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 /> 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 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 torwhich this <br /> 1 permit is issued;=l.shall employ persons subject to workman's compensation laws4of California." <br /> ' caVtoaGrout Insp. # u I g nd a fi _ <br /> Signe <br /> Title: Daie � <br /> (Draw Plot Plan on Reverse Side) <br /> . t <br /> FOR DEPARTMENT USE ONLY E <br /> PRASE I /�`� 4 7 7l' <br /> PP <br /> A lication Accepted By— <br /> Additional <br /> y Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> fEEE 0 <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> `s <br /> OTHER <br /> OTHER ] <br /> �- - <br /> Received by - Date - Receipt No, Permit No �Is ante D to Mailed Delivered <br /> J <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Boa 2009 STOCKTON,CA 95 1 <br />