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.,� <br /> a " Applications Will Be Processed When submitted Properly Completed, Be Sure <br /> APPLICATION <br /> fFOR-101t:ICE USE: f 16,Jill40L, (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaq 'n Loc IHealth District. i <br /> 1 Exact Site Address <br /> City/Town w� <br /> _I t <br /> 1 Owner's Name Of Phone <br /> Address _city_ <br /> Contractor's Name License# d y_'i-7 Business Phone ��` <br /> Contractor's Address o f s� Q Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes_X No n <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT 13OTHER 11PUMP INSTALLATION 13PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> a <br /> Property Line Private Domestic Well Public Domestic Well <br /> l INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 24 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 W <br /> ❑ DISPOSAL ❑ OTHER Other Information S <br /> ❑ GEOPHYSICAL Surface Seal Installed FB <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump44 H.P. / �� <br /> PUMP REPLACEMENT: ❑ State Work Done s <br /> PUMP REPAII State Work Done <br /> DESTRUCTION OF WELL: i Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 ` 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 /> I is issued, I shall not employ any person in such manner as to become subject to workman's compensation iaws of California." <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." <br /> i call for a Grout Inspect` ri grou ' and final inspection. <br /> Signed <br /> tie: t-Date: <br /> `) �f (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 �� <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase It Grout Inspection P ase 111 F'nal Inspection <br /> F � <br /> Date Inspection By Date 6 9-9 <br /> Inspection By � <br /> ! Fee IS Due: El ANNUALLY [:1 PER UNIT Cl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> EMITJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ^' '-L" <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date s 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 2099 STOCKTON,CA 9 <br />