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Applications Will tae Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: '-� APPLICATION <br /> t (For Non-Transferable, Revocable, Suspendable) <br /> I PUMP&WELL <br /> k ENVIRONMENTAL HEALTH PERMIT �{ <br /> o 19 <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY I �s� 3 <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 Joa ul County Ordinan No. 1862 and the r es nd regulations of the San Jo quip Local Ith District. <br /> Exact Site Address a a , Q /l' ,r- R Vep <br /> , City/Town _ <br /> Owner's Name Phone <br /> Address City/ f'4 <br /> Contractor's Named F License# Business Phone <br /> Contractor's Address Emergency Phone <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❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> F 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 e <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing N <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal (n <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type=of-Grout-.�-�-A --_ <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 N <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I �! <br /> Type of Pump M Ar� r HIP._l <br /> 4� PUMP REPLACEMENT: ❑ State Work Done_ .. ,_ - . ' <br /> PUMP REPAIR: ❑ State Work Done <br /> { DESTRUCTION OF WELL: _Well Diameter Approximate Depth f <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 /> GContractor'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 willc II for ro 1ns Idin/pri1 <br /> 'or to grouting and a final inspection. <br /> Signed X G��-� U�-Ga�'��'� Title: Date: <br /> �" <br /> ` (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / ir' <br /> Application Accepted By (�/(/\ 11 Date <br /> Additional Comments: <br /> Phase II Grout Inspection P Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R c By January 31 ❑ Juiy 1 &Received By July 31 <br /> ! <br /> BILLING REMfTTANCE $ REMIT <br /> BASE - EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEED7V �� " <br /> LESS <br /> PRORATION _ <br /> PLUS ,' <br /> PENALTY <br /> 1 OTHER <br /> OTHER <br /> I- <br /> Race d by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: `ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAIELTON AVE.,P.O.Box 2ii STOCKTON,CA 95201 <br /> i <br />