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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 14 <br /> - OW (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �I.S J�.I P� City/Town .42J12� <br /> Owner's Name YJ-A-a4'er Phone <br /> Address 5'S /��rr0� City_- e <br /> Contractor's Name License# Business Phonej'ms's <br /> Contractor's Address �a &,,C—���A � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,�N,,❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER,[] PUMP INSTALLATION 1=1 PUMP REPAIR (I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r ` <br /> Property Line Private Domestic Well Public Domestic Well La <br /> INTENDED USE TYPE OF WELL _J_w <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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Ty of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done,.. 71 axs ��- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 9 <br /> Describe Material and Procedure V) <br /> 1 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." I< <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." fb <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> — 4 Signed X p e`.�s�r_Title: Oate: �� s} <br /> (Draw Plot Plan on Reverse id <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted Date 8 <br /> Additional Comment . <br /> Phase 11 Grout Inspection nie,16, <br /> J�i�allns:pection <br /> Inspection By Date InspectionDate /0 �G <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & 31 ❑ July 1 & e eived By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4S. uo <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY +, <br /> OTHER <br /> OTHER y <br /> Received by 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 />