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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign Inerkppnca1w,1. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WEA L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I WATER QUALITY <br /> (COMPLETE IN TRIPLICATE.) I <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or installthework herein described.This application is <br /> made in compliance with SanJoaquinCounty Ordinance No. 1862nd the rules and regulations of the San Joaquin Local Health District. <br /> p / 1 ..r p ; '. City/Town ,,, f ;�• {l ' f 1 <br /> Exact Site Address <br /> a t Phone <br /> Owner's Name ` ) °; City <br /> Address ' <br /> Contractor's Name j i ":} i t r s D F € License# ? f �' Business Phone <br /> ' r ` - ..3. [ � a <br /> Contractor's Address "=�'�•�s� .� '-' � '""' Emergency Phone0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_21-1/1", No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 11PUMP INSTALLATION 11PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: ' Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Weil _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL y <br /> 13 INDUSTRIAL C] CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C1 DRIVEN ' 'Gauge of Casing <br /> ❑ <br /> DOMESTIC/PUBLIC <br /> ❑ IRRIGATION ` % r.% . _ ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> �1 ❑ OTHER Other InformationEl DISPOSAC__ <br /> _ I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION-- Contractor <br /> Type of Pump I H.P. <br /> 4,4�J_ _ <br /> PUMP REPLACEMENT: ' DEState Work <br /> 0 DoneL/6' <br /> PUMP REPAIR: Work Done: <br /> _ J <br /> Well Diameter <br /> j Approximate Depth <br /> W <br /> DESTRUCTION OF WELL: W _ ., <br /> (,+latbrial yand Pr_ocec, <br /> k <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:1'1 certify that in the performance of the work forwhich this permit <br /> is issued, l shall not employ any person in such manner asAo:b come subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the folidwing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's Cc mpensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inApectioh) r ;> <br /> F".` f. Date: r <br /> r Signed X .�... r _� Title; a <br /> '1 �v <br /> (Draw Plot Plan on_Rerse Side) <br /> I <br /> I FO DEPARI'M{,ENT USE O LY <br /> PHASE 1 Date <br /> -w _�� <br /> Application Accepted By i R <br /> Additional Comments: i <br /> t: t Phase III Final Inspection <br /> Phase II Grout Inspection <br /> Inspection By ` <br /> Date i Inspection By Date <br /> i� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> El ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedJuly 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE .✓�,�� � 1 ��� �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I� <br /> OTHER <br /> G <br /> Permit No. —` Issuance ate Mailed Delivered <br /> Received by Date Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />