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Applications Will Be Processed ften Submitted Properly Completed. Be Sure To Sign The Application. j <br /> FOR OFFICE USE: 1APPLICATION <br /> (4 oii 4 (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL { <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LJ <br /> (COMPLETE IN TRIPLICATE)— .1&IATIR QUALITY <br /> quinLocalHealthDistrictforapermittoconstructand/orin'stalltheworkhereindescribed.Thisapplicationis-r <br /> Application is hereby made tothe an�oa <br /> made in compliance with San Jo quin�CounSy Ordinance No. 1862 and the ,ruulles and re fa ns of the San Joaquin Local Health District. <br /> Exact Site Address �O �� � /u��i� �y✓ _!.r� ��p*City/Town <br /> or <br /> M > <br /> Owner's Name �'� t 'CD W" 1h Phone I <br /> Address 1. ^~7*7 S w4�i "ad City �a7a� j <br /> Contractor's Name S '�� License# /P.._�—__-_�k�siness Phone t�Y �7_6,�� <br /> Contractor's Address �~ �✓ Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance On File Wit 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❑ I c' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f'h <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well i <br /> I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation V . <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing N' <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: V` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I 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, <br /> ountyordinances, 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of tfie work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I pill call for a Grout Ins ion ri r routing a d a final inspection. <br /> Signed Title: Date: <br /> (Draw P t Plan on Reverse Side) <br />€ <br /> FIPIR DE RTMENT SE ONLY <br /> f PHASEI <br /> I Application Accepted By ..Date _1_2� / <br /> I Additional Comments: <br /> E <br /> Phase II Grout Inspection P 111 Final spection <br /> Inspection By Date s14- Inspection ByLDate <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION TE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 4 <br /> FEE Alidc�&of 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 <br /> -71:�1-1 3 Lf 1�t�7� <br /> Received by Date Receipt No Permit No. -Issuance Date Mailed Delivered . <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 1 <br />