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ter"' Applications Will Be Processed When.Submilted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION, <br /> CC) j (For Non-Transferable,Revocable, Suspendable) PUMP&WELL �. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ? WATER QUALITY v4J K <br /> (COMPLETE IN TRIPLICATE) ; QRfE-_LNGt(-.� -.- <br /> Application is hereby made to the San Joaquin Local Health District fora.perrriit to construct and/or install the work herein described.This application is <br /> made in compliance with San.Joaquin County Ordinance No. 1862 and4he�rules and r-au <br /> lations of the San Joaquin Local Health District. <br /> Exact Site Address ti- fo tf't Stm City/Town `L0 1 — /06 _0 ?� <br /> Owner's Name 42 faPhone" ;... <br /> Address Co04 <br /> s- - City <br /> Contractor's NameA. 1:377�M .'-License#-+ F ` ' Business Phone" c: tra2--- G <br /> Contractor's Address "% Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W th SJLHD? Yes YNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ - DEEPEN ❑ RECONDITION❑ DESTRUCTION[:] ' — <br /> ❑ ENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> WELL CHLORINATION WELL ABANDONMENT, <br /> REPLACEMENT❑ V" <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation s <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 150 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 4} <br /> ❑ GEOPHYSICAL- Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT:'- State Work Done <br /> PUMP REPAIR: ❑ State Work Done s ,- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth — <br /> eY Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> tordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> 'i 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 becofne subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracling signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California."; <br /> I will call for a Grout Inspectio i t grou g and a final inspection. <br /> Signed X' tIe: Date: <br /> (Draw Plot tan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE.1 <br /> Application Accepted-By � ,-- � �� � _ ' .`. f �= Date <br /> Additional Comments: <br /> Phase II Grout Inspection' e fll Fin <br /> Inspection By - Date Inspection <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT "❑ PER SITE ❑ EACH -0 anua &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - BASE EXPLANATION BILLING REMI NCE $ MOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 61 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ; <br /> € Received by Date w .-. Receipt No. Permit No. ` . - Is uanc ate -mailed .. Delivered - <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />