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Applications Will Be Processed When Submitted ProperlyCompleted Be SureToSign TneAppllcarlon. <br /> FOR OFFICE USE: APPLICATION <br /> �: Iv <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ii PUMP&WELL , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �7vwE�id�- I61 WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This aplication is <br /> made sn compljance with San Joaquin County rdinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addfess 54333 City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License#��'ciO�P/3 Business Phone <br /> r <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ II <br /> DISTANCE TO NEAREST: Septic Tank _ �/`�� Sewer Lines Pit Privy <br /> Sewage Disposal Field /00 t Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well J <br /> 4 <br /> INTENDED USE Ii TYPE OF WELL <br /> ❑ INDUSTRIAL II ❑ CABLE TOOL Dia. of Well Excavation <br /> X DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing zz) <br /> ❑ IRRIGATION g GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I XROTARY Type of Grout <br /> I ❑ DISPOSAL �i 11OTHER Other Information r <br /> ❑ GEOPHYSICAL I, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a H.P. <br /> PUMP REPLACEMENT: ! ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ii 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 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." ca <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 /> J> <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X �`+ '� " Title: Date: <br /> (Dra Iot;Plan on Reverse Side) IV <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By �i `�lv� Date <br /> Additional Comments: <br /> Ph se I rout Inspection / Phase III Final Inspection <br /> Inspection By r Date (�` E Inspection By .. Date <br /> F <br /> Fee Is Due: ❑ ANNUALLY I;' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> BASF EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> I FEE 3 <br /> LESS h] <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Re eived b D e Receipt No. Permit Iss ante to Mailed Delivered <br /> APPLICANTRETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 95201 <br /> .— <br />