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ApplicationsWill Be Processed When SulimitfirdJ operly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: -APP <br /> (For Non Transferable,`Revocable Suspendabte) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 o. 1862 and the rules and regulati ns o th San work <br /> he ocaf Heal Distract. <br />' Exact Site Address���_p�� _;��;, .—� �-� e <br /> Owner's Name <br /> Address Phone <br /> City <br /> Contractor's Name License# Y�(1 <br /> Contractor's Addr _A1 2-4:115111 <br /> ess �� ��® 6% - Business Phono <br /> �Zs-SAVEmergency Phone -5345-7-4.27-/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X__ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0P <br /> REPLACEMENT❑ PUMP REPAIR❑ ( <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage <br /> ^ g Disposal Field Z00 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ? TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOLN <br /> Dia. of Well Excavation <br /> s X DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing �Y <br />` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout.Seal <br /> ❑ CATHODIC PROTECTION ROTARY <br />` <br /> DISPOSAL � Type of Grout <br /> OTHER Other Ihformation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP-REPLACEMENT: ❑; State Work Done :E <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 <br /> Joaquin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. q Y <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 sup-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit call for a Grout In ection prior to grouting and a final inspection. I <br /> Signed X Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date C' # <br /> Additional Comments: <br /> ase II Grout spection ase III Fi al Inspection <br /> Inspection B ate - 9-S Inspection B <br /> P Y �Date .1_2,-:: -,FC) <br /> Fee <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE yi C/3 0 <br /> or 3 <br /> E LESS ! <br /> PRORATION <br /> PLUS ---------------- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byate 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 STOCKT.ON,CA 95201 <br />