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Applications`Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> t <br /> i ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joa u�in ounty Ordinance No.1862 and the rules and regulations of the San Joaquin Locai Health District. <br /> Exact Site Address ,tLAA Rd City/Town I <br /> Owner's Name Phone <br /> Address111�11( 0 <br /> C+ty <br /> Contractor's Name License#f� Business Phone Gam; <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❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ! <br /> REPLACEMENT❑ <br /> I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_l4� <br /> SewiPit Privy II <br /> ! 1 <br /> age Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f J <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation /L _ <br /> ,,DOMESTIC/PRIVATE DRILLED Dia. of Wel! Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing x <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4:1107rL , } <br /> PUMP INSTALLATION: Contractor ' <br /> I <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 /> I Describe Material and Procedure $Z11 <br /> Qq <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J)j <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:"I certify that in the performance of thework 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-conlractinglsignature certifies the following:"I certify that in the performance of thework forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." 11111 <br /> I <br /> I will call for a Grout Inspection prior to grouting and a final inspection. ) <br /> Signed X r eye Title: Date: U C—J rri <br /> (Draw.Plot Plan on Reverse Side) i <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> Application Accepted ByGti Date <br /> Additional Comments: �1•- <br /> n <br /> Phase,ll Grout Inspec(- 9-- <br /> Phase Ill Final Inspection <br /> Inspection By li DaInspection By j_ 1Date 4 <br /> Fee Is Due: E.1 ANNUALLY i.Q PER UNIT PER SITE ❑,EACH ❑ January,1 &Received By January 31 ❑ July 1 &Received By July 31 - - <br /> I <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED ' <br /> AMOUNT <br /> ab i l i <br /> FEE <br /> LESS ;Ifl �- - 7-4 <br /> - <br /> PRORATION <br /> PLUS <br /> PENALTY :I�l <br /> OTHER <br /> OTHER F _. <br /> III, � <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, 201 <br /> 4 3 <br />