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Applications Will Be ProcessedWhen Sugmmeotropeny%,ompleii DrOUre rV�IVIF 1— <br /> FOR <br /> —FOR OFFICE USE: y?� APPLICATION ! <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 he.rein described.This application is <br /> made in compliance with San Joaquin County Or finance No. 1862 and the rules and regulations of the San J aquin Local Health District.. I <br /> Exact Site Address City/Town <br /> 3 <br /> Owner's Name Phone k <br /> Address e ` �� City <br /> , <br /> Contractor's Name % License#� Business PhoneJ�[� <br /> Contractor's Address Emergency Phoneme <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECKJ: NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I <br /> -WELL CHLORINATION Cl WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR i <br /> REPLACEMENT❑ f + <br /> DISTANCE TO NEAREST: T Septic Tank, Sewer Lines Pit Privy ( <br /> Sewage Disposal Field" (- � _ r iesspooI/Seepage Pit _y1ra� Other r• <br /> Property Line" �Private Domestic W611 _ (Publicc Do, c We11 � ... <br /> INTENDED USE TYPE OF WELL`S? <br /> ❑ INDUSTRIAL CABLE TOO-'LIiZ' []ia.. �f'Well Excavation <br /> I+ ~� <br /> JM DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ( ! <br /> C&DOMESTIC/PUBLIC 13DRIVEN 'f Gaif Casing f <br /> ❑ IRRIGATION ❑ GRAVELPACK "Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY �Typel f Grout !. <br /> ❑ DISPOSAL' " ❑ OTHER fi Othe�r'Information <br /> ,fir �, <br /> 11 GEOPHYSICAL ; Surface Seal Installed By: <br /> PUMP INSTALLATION-d r Contractor <br /> Ie" <br /> , -----, <br /> { Type of Pump ` , <br /> PUMP REPLACEME14T7�` d ❑ State Wo k'Dbne ` ..w- _ - - -•- u <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter '�'^'�—� Approximate Depth , <br /> Describe Material a'nd Procedure <br /> * I hereby certify that I have prepared this application^and-that-4he work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and`ruI's and'regulatio s=of,the-San Joaquin-Local Health District. { j <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance the#work for which this permit <br /> is issued, I shall not employ person in such manner as to become subject to workman's compensation laws of Californias <br /> any <br /> Contractor's hiring or sub=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 * - <br /> I will call for a Grout Inspection prior o grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) f{E <br /> FOR DEPART NT USE ONLY r 1 <br /> ' PHASE 1 _ 'Q l <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout 1nsPection r pha a 1!I Final I�nspe tion <br /> Inspection By Date VU <br /> /-7 Inspection By Date <br /> t I <br /> Df i Fee IS Due: ❑ ANNUALLY )':'❑ PER Ii �p PER SITE � ❑ EACH El January 1 &Received 8y January 31 ❑ July 1 &Received 6y July 31 <br /> k �F REMIT <br /> _ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE' EXPLANATION DATE DATE REMITTED �p (y AMOUNT <br /> 4 FEE D <br /> LESS <br />' IE PRORATION - - <br /> } PLUS <br /> }' PENALTY 'r <br /> 4 E <br /> ' 1 OTHER <br /> I-6THEIR - <br /> Received by Date Receipt No. Permit No. ssuance ate Mailed Delivered r <br /> - APPLICANT—RETllRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2069 . STOCKTON,CA 9520 <br />