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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFME USE: z f APPLICATION <br /> I <br /> _ (For Non-Transferable, Revocable, Suspendable) r " ^--�- <br /> "'� - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance vy.ith San Joaquin County Ordnance No.1862 nd.he rules and regulatio s off�e an J aquin Local H alth District. <br /> Exact Site Address � � P `• + L6 ii..(t — y i' / * a t <br /> Owner's Name . Phone ' ^• C� <br /> Address ^{ City <br /> Contractor's Name Aonn it1 License# Business Ph ne <br /> Contractor's Address _fit( C OMV- Emergency Phone �,1 <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❑ tiR, <br /> REPLACEMENT❑ - �� <br /> DISTANCE TO NEAREST: Septic Tank jWfl , 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 11.3 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of CasingCI�Ai _. <br /> X IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of GroutIlJi <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 1. <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 <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 for which 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 final4rispection. <br /> r <br /> Signed X <br /> � L.. _... Date: <br /> {Draw Plot Plan on Rever Sade) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE l �^ <br /> Application Accepted By \��� - .. Date �D <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection { <br /> Inspection By Date Inspection By Date I <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �� I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r r <br /> Received by I Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />