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r Applications Will Be-Processed When Submitted Properly Completed. BeSureToSign TheApplication.. <br /> i <br /> FOR OFFICE USE: APPLICATION F <br /> (For Non-Transferable, Revocable,Suspendable) <br /> - PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. ; <br /> Exact Site Address IRi�► �t+�+Ct'L � � � City/Town / <br /> Owner's Name /� Phone td 2 <br /> Address � ��/ �. City <br /> Contractor's Name License it Business PhoneT� op <br /> Contractor's Address Q ..�' Emergency Phone p <br /> Is Certificate of Workman's Compensation Insura a on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2§"— PUMP REPAIR❑ <br /> REPLACEMENT❑ �F <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 7. Pit Privy <br /> Sewage Disposal Field_]X 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 /> Z?nOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION_ F-1GRAVELPACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor v e f <br /> Type of Pump N H.P. fi <br /> PUMP REPLACEMENT: Cl State Work Done <br /> PUMP 1R: <br /> 'ElState Work Done O <br /> Approximate Depth <br /> UC <br /> ESTRNOF WELL: Well Diameter PP p <br /> �Describe Material and Procedure IC <br /> 1 <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 /> Home owner or licensed agent Ls signature certifies the following:"I certify that in the performance of the work for which this permit l <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 for which this <br /> n <br /> permit is issued, I shall employ persons subject to workman's compensation laws at California." <br /> I will call for a Grout ection prior to grouting and a final inspeclI <br /> Signed X Title: Date: <br /> `i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By '�'`"'cam•._ Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas I11 Final Inspection 1 <br /> _71 <br /> Inspection By�_��:-- Date Inspection By Da e <br /> Fee I5 Due: ❑ ANNUALLY - ❑ PERiUNIT ❑ PER SITE -❑ EACH ❑ January 1 8 Received By Januar 1 - - ❑ July 1 &Received By July 31 <br /> t. I -- REMIT <br /> BASE EXPLANATION BILLING - REMITTANCE $ AMOUqDUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1� <br /> LESS <br /> III PRORAT4ON <br /> PLUS <br /> PENALTY _ - <br /> i <br /> i OTHER <br /> t <br /> OTHER <br /> t 'Received by Date Receipt No Permit No - _ Is uance D to - Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: t ENVIRONMENTAL HEALTH PERMIT/SERVICES - ISM E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />