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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Applica Ion. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> a ENVIRONMENTAL HEALTH PERMIT <br /> 1 r� WATER QUALITY ,�. kfit <br /> (COMPLETE IN TRIPLICATE) ! -�L � <br /> Application is hereby madeto the San Joaquin Locat Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with an Joa uin Co/Unty Ordinanc 18 nd the rules an r gulati ns o the San Joagu� Local Health District. <br /> c[C71 O itt4'^L YCct <br /> Exact Site Address i� y <br /> „t. Phone :TG 7 �5/ <br /> Owner's Name City. «[a- <br /> Address City <br /> r License fig ' ?ll Business Phone �/�'•Z�� �; <br /> Contractor's Name Edo <br /> Contractor's Address "Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> _y> <br /> TYPE OF WORK (CHECK): NEW WELLK DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTOI <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �d _ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property LineZQ�_Private Domestic Well <br /> _$Public Domestic Well <br /> INTENDED USE TYPE OF WELL r� <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r ff <br /> ❑ DOMESTIC/PUBLIC C] DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ <br /> ❑ OTHER DISPOSAL 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 <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 p ons subject to workman's compensation laws of California." <br /> I will call for a ut pec o nor to_grouting and a final inspection. t <br /> Signed X <br /> I Title:. Date: <br /> (Draw Plot Plan on Reverse Si e) <br /> s FOR DEPARTMENT USE ONLY <br /> t, <br /> , PHASE I Date : <br /> Application Accepted By t <br /> Additional Comments: r <br /> I Phase It Grout Inspection Phase 111 Final I action <br /> ' Inspection By <br /> Date v Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1'&Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> FEE �— <br /> LESS <br /> PRORATION <br /> PLUS' <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Mailed Delivered <br /> Received by Date Receipt No. <br /> Permit No. Issuance ate <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16D1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />