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Applications Will Be Processed When SubmittedProperlycomplecea. esejure iv01911 rna•+rN•��••� ` <br /> FOR1_�JCEsE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work h rein described.This application is <br /> made in compliance with San JoaquinC unty di anc,eNo. 1862 and the rules and regulationwf " in Local Health District. <br /> Exact Site Address - r� .�AJQr ��A" City/Town rs <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Jam. �_7 <br /> nse# Busin�ess!Phone <br /> Contractor's Address 5 Emergency Phone �JrJ 7� J <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes l~/ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONED DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tankd Sewer Lines Pit Privy <br /> Sewage Disposal Field .1�` Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> 1 <br /> INTENDED USE TYPE OF WELL /W <br /> ❑,, INDUSTRIAL El CABLE TOOL Dia. of Well Excavation N <br /> ugr DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing 4G <br /> 13DOMESTIC/PUBLIC C1IVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION UP90TARY Type of Grout W <br /> 1:1 DISPOSAL 1:1OTHER Other lnfbrmation r <br /> 11 GEOPHYSICAL _ Surface Seal Installed Bye- <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth a <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,certifles 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil",,,�Ior a <br /> Grout Ins tion prior 1 grouting and a final i"ection. <br /> g date: <br /> Si red X (Draw Plo Plan on Reverse ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE �Z} <br /> Application Accepted By Her Date <br /> Additional Comments: <br /> Ph 11 Gro 1 Inspection Phase III Final inspection <br /> Inspection By <br /> Date Inspection By - Date <br /> _ YF <br /> Fee IS Due: ❑ ANNUALLY El PE UN T '❑ PER SITE ❑ EACH ❑ January 1 8 Receive By 3anuary 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXP NATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE +�cREMITTED AMOUNT <br /> FEE <br /> LESS ° Ll 3 <br /> PRORATION �' <br /> 100. <br /> r <br /> PLUS Y <br /> PENALTY p <br /> OTHER <br /> OTHER <br /> Received by ate Receipt No. Permit No. Issu nce ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95204 <br />