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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �77 <br /> � /\/,, WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or Install the work hedein described.This application is <br /> made in compliance with San JoacWin County Ordinance No. 1§62 and the mulles and regulations of the San Joaquin Local Health District, <br /> Exact Site Address !/O/r✓� F Ra-0 - City/Town C Ce4 e�! <br /> Owner's Name i ��� Phone6 <br /> Address 1'0 ZAf r66� City LcI V� <br /> Contractor's Name (5-f cot ) License# Business Phone <br /> n <br /> Contractor's Address / �L P-''O Ire e- 0 Lit' Emergency Phone <br />"'O'-s Certificate of Workman's Compensation Insurance on File With SJLHD? " Yes 5>e No <br /> TYPE OF WORK (CHECK): NEW WELLX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i 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 /o ' <br /> ❑ iRRIGATION GRAVEL PACK Depth of Grout Seal Q) <br /> ❑ CATHODIC PROTECTION b<ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information + <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ <br /> Type of Pump H.P. <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 41 <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:"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 Ins ection prior to grouting and a final inspection. <br /> Signed X Title: � �/f� � Date. <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By '� f A Date <br /> Additional Comments. JLIe <br /> as I Grout Inspection r� ase Ill F a spection / <br /> knspection By Date Inspection By ! . <br /> F <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION PATE GATE REMITTED AMOUNT DUE CHECKED t <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Z-7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />