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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application'. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) I 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 wit j San.J9 in Court Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address fad A City/Town <br /> - <br /> Owner's Name ! Phone <br /> Address <br /> Contractor's Name _ -� City <br /> � Licensees Business Phone fes' <br /> Contractor's Address ' , �' 6 - ��f tt r c Emergency Phone <br /> k Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes tom'' <br /> No _ <br /> TYPE OF WORK (CHECK): NEW WELL&]-' DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION-D— PUMP REPAIR❑ <br /> r REPLACEMENT❑ <br /> .._7 <br /> DISTANCE.TO NEAREST: Septic Tank a " ' Sewer Lines 10"e-el-I ll'"- Pit Privy <br /> Sewage Disposal f=ield -GesspobVSeepage Pit " Other <br /> }, <br /> Property Lines'' Private Domestic Well 2f--01L- Public Domestic Well <br /> INTENDED USE TYPE OF WELL r t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r 9��OMESTIC/PRIVATE *pRILLED Dia. of Well Casing 'f <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,❑ GRAVEL PACK Depth of Grout Seal ' l� <br /> i ❑ CATHODIC PROTECTION E3 ROTARY Type of Grout r �� <br /> ❑ DISPOSAL ❑ OTHER 'Other Information <br /> ❑ GEOPHYSICAL '� Surface S,�al Installed By: f <br /> PUMP INSTALLATION: Contractor ''- ' ; % '. 3 _ , <br /> Type of Pump ,"&`69 H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: _ ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameters 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 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 shallnot employ any person-insuch 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 /> 1 will call for a Gro 1 In ection prior to grouting and a final'Inspection, t <br /> Signed X +, <br /> Title: Date. <br /> (Draw Plot Plan on Reverse Side) f <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION I <br /> F <br /> PLUS <br /> PENALTY -*$ <br /> OTHER a y r w •G ,� - L t�° <br /> OTHER <br /> Received bye Date Receipt No, • Permit No. Iiistipnce to Mailed Deiivered <br /> - -+. <br /> APPLICANT—RETURN ALL COPIES TOr ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />