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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �FUSE: APPLICATION <br /> s (For Non-Transferable, Revocable, Suspendable) <br /> I PUMP&WELL <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> ,t QUALITY <br /> (COMPLETE:IN TRIPLICATE) WATER Q1� <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This appliq$tion is <br /> made in corrlpliance with San Joaquin County Ordinanc N .1862 and the rules and regulations of the Sa rL Joaquin Local Health District. v� <br /> Exact Site Addressd City/Town C�z1_ 1* — LCJC� C/CEJ <br /> f 0 IF <br /> Owner's Name Phone ���Ha RR <br /> Cit ak <br /> Address y <br /> ij Contractor's Name License#�O�I Business Phone ` <br /> °I Contractor's Address keg rgency Phone <br /> i <br /> Is Certificate of Workman's Compensation Ins rance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El RECONDITION❑ DESTRUCTION❑ <br /> ! WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ l <br /> i� REPLACEMENT❑ <br /> ! DISTANCE TO NEAREST: Septic Tank le7Q Sewer Lines Pit Privy <br /> I� Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> !r <br /> INTENDED USE TYPE OF WELL <br /> J ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1i -- <br /> li DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a laze <br /> �� ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> �i ❑ DISPOSAL ❑ OTHER Other Information -- p <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .i <br /> Type of Pump H,P. <br /> I� Ii ' <br /> PUMP REPLACEMENT: ❑ State Work Done, v <br /> PUMP REPAIR: ❑ State Work Done <br /> d DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ------- <br /> I <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:A certify that in the performance of the work for which,this permit <br /> 13. is 'Issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> h Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspect'on prior to grouting and a final inspection. <br /> I 'I Signed X Title: Date: <br /> l ; <br /> 1� (Dr Plot Plan on Reverse Side) <br /> t ' FOR DEPARTMENT USE ONLY <br /> t I� <br /> PHASE <br /> f . Application Accepted By r Dated f <br /> Additional Comments: <br /> 14 a rout Inspection Phase III Final Inspection <br /> lit Inspection By Date Inspection By� �� Date <br /> Iy � <br /> 4 Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1.&Received By July 31 <br /> 11 REMST <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE `' CHECKED <br /> 4E DATE DATE REMITTED AMOUNT <br /> FEE L1 <br /> LESS <br /> PRORATION <br /> PLUS 1P <br /> PENALTY <br /> OTHER _ <br /> �I OTHER <br /> 9S -7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ,.� <br /> 1&01 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />