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ApplicationsWillBeProcessedWhenSubmllledProperly L;ompletea. rse sure losign lneAppllcailon. <br /> FOR OFFICE USE: Q ( APPLICATION <br /> 66 I004 For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> E (COMPLETE IN TRIPLICATE) p' � p_ _ATE gUALITY <br /> 5 fie` 7 �. ref' � d .�_.� <br /> Application is hereby made to the an Joaquin 1Local Healt Districtforapermlttoconstructand/or install the work herein described.This application is <br /> made in compliance withlS i�tV rdinance No. 1862 and the rules and reguI ions of the San Joaquin Local Health District. <br /> Exact Site Address 3/ aY a"E p � c,1�r City/Town <br /> Owner's Name o�tc.? I/'t `1=3� Phone <br /> Address ,x _-L A �` _ Citv /I 1r14'1111 <br /> Contractor's Name S M, GG/ FAQ License# I'�' 734 Business Phone yele 1r —124 ? <br /> Contractor's Address 'n cy Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> J4 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal h <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump ✓ H.P. / !� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done o <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y) <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 /> 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 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 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 inspection p f grooina and a final inspection. <br /> Signed . Let1e: �"a-� Date: 4 it <br /> �(DTwPlw�an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> PHASE I ►� rte_ <br /> Application Accepted By Date o- <br /> Additional Comments: <br /> Phase II Grout inspection Phase 111 Final Inspection <br /> Inspection By JN NO Date Inspection By Date <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT T <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS 7 r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6iLiS II <br /> Received by Date Receipt No. Permit No. Issuarice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />