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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR dFFICE USE: APP�-ICATION <br /> y : <br /> (For Non-TransleraShble, Rirvocable, 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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ,Cro/unty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> --2 <br /> Exact Site Address a 7—W M-&K1«4-6 797 City/Town - <br /> Owner's Name �L Phone 7� 3¢ <br /> 67 <br /> Address / City <br /> Contractor's Name 6 76U,/Aff License#3�;7eYZ Business Phone 7_51eF—3377 <br /> Contractor's Address T-6- 3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance an File With 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❑ <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 50 CABLE TOOL Dia. of Well Excavation <br /> 0 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 11 ROTARY Type of Grout �? f MEil/T �T- [ <br /> El DISPOSAL El OTHER Other Information °� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: lel 441-1il/ <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 <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:1 certify that in the performance of the work lorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I It call for a Grout Inspection prior to grouting and a final inspection. <br /> !X/IUB O� L®.� <br /> Signed X __ Title: Date: �^Y <br /> {Draw Plat Plan on Reverse Side) y <br /> 1 <br /> FOR DEPATMENT U E ONLY <br /> �+ <br /> PHASE I "'a ~� <br /> Application Accepted By Date <br /> a <br /> Additional Comments: <br /> II Grout I petrtian�., a III Fina Inspection i <br /> Inspection By4yh P Date / Inspection By Date <br /> L <br /> "MawFee Is Due: El ANNUALLY ❑ PER UNIT tQ lro�PER SITE ❑ EACH © January 1 $Received By January 31 ❑ July 1 $Received By July 31 <br /> BILLING. REMITTANCE $ REMIT <br /> BASE EXPLANATION 15AT� DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I5 anc Date Mailed Delivered _ <br /> . /� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVIC5P2 �A 1601 E.HAZELTON AYE.�,p �o■2009 .STOCKTON,CA 85201 <br /> � SfU <br />