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Appl'icait,rL +� moused When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> n ' <br /> For Non-Transferable, Revocable,Suspendable) <br /> a PUMP&WELL <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> ATER QUALITY 10.5'_050— OS <br /> Application is hereby made to the San Joaquin ocal Health District for permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin unty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> i Exact Site Address 0,-. m - � , ✓ City/Town <br /> 01 <br /> - <br /> Owner's Name02 <br /> ." `` Phone <br /> Address _ City 'OltC <br /> Contractor's Name. `Ui ase# Business Phone <br /> J <br /> Contractor's Address Emergency Phone -C <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❑ Y, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> j 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 /> _-'DOM ESTIiCLPRIVATC-> ❑ DRILLED Dia. of Well Casing <br /> 1 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - <br /> 5 <br /> C3 IRRIGATION 11 GRAVEL PACK Depth of Grout'Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor9�� <br /> %Type of Pump H.P. <br /> _171K <br /> , <br /> PUMP REPLACEMENT: ❑ State Work Done _ R <br /> PUMP A State-Workk-Done—_�-_f"�:41 =Depth — <br /> Describe <br /> DESTRUCTION OF WELL: Well Diameter ApproximatMaterial 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w'I call for a Grout Inspec on r r o grou ' g and final ins tion. <br /> Signed Itle: Date: <br /> (Draw,Plot an on Reverse Side) <br /> �. FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> Application AcceptedyBy � 1 � �� �� ' - Date AV <br /> Additional Comments: <br /> Phase II Gro t Inspection �� ��, �P Phase i a I spection <br /> Inspection By �IJ-�sdNn� l�spection B <br /> Fee IS Due: ❑ 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ 3 _ <br /> Received by - Date Receipt No, - - Permit No. - - Issuance Date Mailed Delivered <br /> $ APPLICANT—RETURN ALL COPIES TO!- ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />