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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,kelrocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTHPERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY .,_ <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or installthework_herein described.This application is <br /> made in with Sa oaquin County Ordinance o. 1862 and he rules and regulations of the San o�aqui} Local Health District. <br /> Exact Site Address r} City/Town <br /> Owner's Name ; °' :"_ Phone �' l 3 'a3 <br /> Address ;City <br /> Contractor's Name x License 3 73 Business Phone .3 <br /> Contractor's Address '• r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes c� No 6"^ <br /> TYPE OF WORK.(CHECK): ANEW WELL❑_ DEEPEN ❑ � RECONDITION❑ DESTRUCTION❑ ` T" �} <br /> WELL CHLORINATJk3N ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11 'PUMP REPAIR❑ b) <br /> REPLACEMENT[�' r - v <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 i <br /> �❑f DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` <br /> -# IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout { <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r ^ �_+y,,r _, urface Seal Installed By: 1 <br /> PUMP, INSTALLATION: Contractor <br /> IT of Pump H.P. ._ '7 <br /> PUMP REPLACEMENT: ! State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter l Approximate Depth <br /> Describe Material and Procedure J '= <br /> d ! i <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. rtify that in the performancdof the work:forwhich this permit <br /> is issued, I shall not employ any person in such manner-.as.to become=subject to_workman's_compensati'bn 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." y <br /> e. <br /> IW <br /> i all for Gro I pe n prlor to grouting and a III n'If ns coon. <br /> ` J - <br /> Signed X. _ tie:� 'Date• 74>--- <br /> / <br /> � <br /> (Draw Plot Klan on Revers Side) � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � y yp <br /> Application Accepted'By -' i -- Date D <br /> Additional Comments: <br /> Phase 11 Grout Inspection �F Ph Se Ill Final ins coon <br /> Inspection By Date Inspection EIV <br /> ate l` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received BVJanuary 31 Q July 1 &Received By July 31 <br /> BILLING. REMITTANCE _ $ REMIT <br /> .BASE s EXPLANATION � AMOUNT'DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ! # <br /> PRORATION <br /> PLUS ..� .. <br /> PENALTY i <br /> OTHER <br /> OTHER } <br /> Received by Date Receipt No.: Permit No - Issu nce 4Date5_ Mailed Delivered- - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95241 <br /> r <br />