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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> 'FOR OFl:tCE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address g7t aft Q d. City/Town S �N da r <br /> Owner's Name 1 Phone ag 7— 3 o��4 <br /> Address ti A -C-11 Ic City <br /> Contractor's Name GOA Lic se#Y Business Phane_d,/� �t�3 7 <br /> Contractor's Address Emergency Phone Q*!L i 9 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ^' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DE— <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION + PUMP REPAIR❑ N' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank f!1.5'f Sewer Lines Pit Privy Q <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 11-s <br /> Property Line Private Domestic Well Public Domestic Well l , <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL '` Dia. of Well Excavation f <br /> 4 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 Type of Grout ag <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r 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 <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." <br /> Contractor's hiring or sub-conlracting 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 prion to grouting and a final Inspection. .may <br /> Signed X h aA _Cey�vt.� Title: T y`r �y y Date: ! �_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> Application Accepted By ...Date' <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By_14T!!A Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 7 <br /> LESS 1l c�O <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L 915 <br /> Received by Date 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 />