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t ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �, z <br /> I FOR OFFICE USE: APPLICATION " <br /> u (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT �! PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ; <br /> Application is hereby madeto theSa6 Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is <br /> 4 made in compliance with San Joaq iu,in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ I I y II' S. l c�►rczmerL 5 City/Town x° -,,j <br /> Owner's Name �.\a Phone 3�— <br /> Address �. 'i�i - e S City�C7Z"—A Q j <br /> Contractor's Name 511 �C]S ,"I,u License#l�1 k Business Phone 4'S` <br /> Contractor's Address _ Z5 Emergency Phone <br /> i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL& DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> l <br /> DISTANCE TO NEAREST: Septic Tank 1ead'+- _ Sewer Lines Pit Privy <br /> Sewage Disposal Field !OQ , 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 4 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing QVC• _ cam, 0. <br /> ❑ IRRIGATION 59 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout !! <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 't <br /> Surface Seal Installed By: <br /> Vk- <br /> PUMP INSTALLATION: Contractor <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 <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 <br /> .11 <br /> gent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not emplloy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sup-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." <br /> I i <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X � Title: • Q. Date: ._/ ' r <br /> I` (Draw'Plot on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I it <br /> Application Accepted By Date <br /> Additional Comments: <br /> hl. <br /> Ph e I rout Inspection Phase III Final Inspection <br /> I nspection.By Date <br /> Inspection By <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT 13 PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION I! <br /> PLUS !I�, <br /> PENALTY i <br /> OTHER I <br /> OTHER <br /> 16 7 <br /> Received by ate jN Recei t NO <br /> Permit No. Issuance Date Mailed Delivered J <br /> APPLICANT—RETURN ALL COPIESiro: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 •'+ <br />