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E Applications Will Be Processed When Submitted Properly Completed.BTj <br /> eJr0.7i)k$_1g!!?TIJt fL410 b I <br /> IEI APPLICATION <br /> FflR' FICE USE: ff{JIf f <br /> i 44 <br /> t (For Non-Transferable, Revocable,Suspen b ) <br /> JUNa JUN I 198PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SA;Nf <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inSta�IJ tkie wvfk (eir[ bed.This application is <br /> made in compliance with JoaquiQ County Ordinance No. 1862 and the rules and ragulations o he SaV?gqui�t Local F[ealth Distri <br /> Exact Site Address �' '� d' �• �` � <br /> Owner's Name Phone _ � �T ?_� g <br /> Address City <br /> Contractor's Name License# -I Business Phone, ��__7�[y � <br /> i Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensatio Ins rance on File With SJLHD? Yes No 0q <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 Serer Lines t c r/ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I� <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IpOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> !�❑ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout -� <br /> 13 DISPOSAL *❑ OTHER Other Information <br /> k <br /> ❑ GEOPHYSICAL Surface Seal Installed By: s^lC;a�__r., �! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 5 ❑ <br /> PUMP REPLACEMENT: State Work Done <br /> f PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL:. Well Diameter - Approximate Depth <br /> f 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 /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will r a Grout In pe ion prior to grouting and a final inspection. <br /> Signed X Title: -, Date: <br /> ' aw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,,1�[1j , Date <br /> Application Accepted By <br /> Additional Comments: <br /> ' <br /> Pha5e 11 Grout Inspection r Phase 1!1 Final Inspection <br /> Inspection By Date —[L— r. Inspection By Date <br /> Fee Is Due' ❑ ANNUALL4411,91�1 PER-UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> �. <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I - - DATE. DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 con,a 1 � <br /> t Received by Date - Receipt No. Permit No. Issuance Date Mailed Delivered +l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f <br />