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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: ( APPLICATION i <br /> (For Non-Transferable, Revocable, Suspendable) <br /> -'- <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin County Or ce No. 1862 and the rule and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_G�1/� 36 / 56. City/Town <br /> Owner's Name Pft1,2,Ch10 Phonerr. _ <br /> Address F City�7, , <br /> Contractor's Name License#339` 0/ Business Phone_P_21_ 225-1y _T <br /> Contractor's Address r <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wth SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER 13PUMP INSTALLATION 6 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 /> ❑ IrUSTRIAL 11 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 F Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. 4111@DLL" <br /> PUMP REPLACEMENT: ❑ State Work Done S <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 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 forwhich this a <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> .r <br /> I I for a Groat Inspecti n prior to grouting and a final inspection. 4 <br /> Signe Title: Date 5 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY y-s <br /> PHASE I Application Accepted By Date d01 <br /> d <br /> Additional Comments: ! <br /> Phase 11 Grout Inspection se III Fin I Inspec,' n <br /> Inspection By Date Inspection By D�{e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �' + <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No. lssfuan8Dite Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON'AVE.,P.O.Box 2009 STOCKTON,CA 95201 ''J <br />