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1 wppticationsWill Be Processed When Submitted Properly Co let�.� S s� <br /> ' 11�^ gn�7►e kation. L <br /> FOR-OFF-ICE tisE: APPLICATI I e o , <br /> (For Non-Transferable, Revocabl , spenda�blleO 19�� <br /> ENVIRONMENTAL HEAL PERAIT` t vU PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYC NL <br /> + ) �± <br /> Application is hereby made tothe San Joaquin Local Health <br /> Districtforapermittocon struct$1 r�nU"th rkPhbeindescribed,Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regula i s of the San Joaquin Local Health District, <br /> Exact Site Address - 1-7 112 <br /> Hf Gity/Town <br /> Owner's Name !! Dn! Phone <br /> Ad d ress City <br /> Contractor's Name License#I_ � Business Phone 6 ro <br /> Contractor's Address -6 Emergency 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❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION" PUMP REPAIR <br /> REPLACEMENT❑ �J <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 Typo of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: W t <br /> PUMP INSTALLATION: <br /> Contractor <br /> 14 <br /> � <br /> Ty(pe of Pump H P <br /> PUMP REPLACEMENT: r0 State Work Done _ <br /> PUMP REPAIR: ❑ State Work Done 01 r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _f <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <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 forwhich 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." f <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 prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> Tr (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE <br /> p. 4 <br /> Application Accepted By Date �a <br /> Additional Comments: t <br /> Phase i <br /> III Grout inspection } <br /> P e II final Inspection <br /> Inspection By Date Inspection By �- Date 4 <br /> `Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -Pk-PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 `k <br /> REMIT + <br /> BASE EXPLANAT{ON BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT d <br /> FEE <br /> LESS '1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> z <br /> shy S s ' <br /> Received by DateReceipt No. Permit No. Issuance Date Mailed—Delivered <br /> ^ <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 952�r'..,Q <br />