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Applications Will Be P-socesse When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FGA OFFICE USE: APPLICATION <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. u <br /> Exact Site Address .S City/Town G ; <br /> Owner's Name _ zz All 4? Phone 7 <br /> Address �_� 7 City ; <br /> Contractor's Name License# Business Phone f <br /> Contractor's Address ,T_- �s.—�___._�•dc�7 Emergency Phone F <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR' '( <br /> REPLACEMENT❑ ! <br /> t <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 <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 ; Surface Seal Installed By: <br /> PUMP INSTALLATION:° Contractor <br /> tTYpe of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done r <br /> PUMP REPAIR: State Work Donef <br /> DESTRUCTION OF WELL: i 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> II Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> E:. <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. 7 <br /> Signed X %���'`-� Title::- Date: � -o <br /> [I (Draw Plot Plan on Reverse Side) <br /> i j <br /> FOR DEPARTMENT USE ONLY <br /> J <br /> PHASE <br /> Application Accepted By bate <br /> Additional Comments: 1 <br /> Phase II Grout Inspection h na Inspection <br />'j Inspection ByDate —Inspec n-B to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Re eived January 31 July Received By u <br /> 4 REMIT <br /> BASE EXPLANATION BILLING � rREMITTANCE - AMO ^T DUE CHECKED <br /> CAME �. :.r.. -.DATE - FIFW - AMOUNT <br /> /nom, <br /> FEE - ✓r <br /> LESS <br /> PRORATION _ <br /> -PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> -7 l3 la I�-1 <br /> I Received by Date .Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> ' •APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O..Bo■2009 STOCKTON,CA 95201 <br />