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Ap:nueotronsWillBeProcesses when auommea rraP+wrr a vu.r.•� <br /> F"OFFICE APPLICATION " <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELT. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 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 application is <br /> made in compliance with San Joaquin County Ordina ce No 186a and the rules andegulatii'on�� ,San Joaquin Local Heai�h District <br /> Exact Site Address D I / ow r ' <br /> Owner's Name ` Phone 9oZ� <br /> Address City <br /> Contractor's Name License#�_ Business Phone — <br /> Contractor's Address S mergency Phone Ls <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1t' No <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 Sewer Lines Pit Privy <br /> Sewage Disposal Field 00 iCesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> IN-`ENDED USE TYPE OF WELL .0 <br /> ❑ IND0STRIAL El CABLE TOOL Dia. of Well Excavation <br /> DO�'k%'�STIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRR:aATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. = <br /> PUMP REPLACEMENT: ❑ State Work Done -` <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 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 all for a Grout Inspe n prior to grouting and a final Inspection. <br /> Signed X Title: Date: 3 <br /> (Drf Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I4X_19_ <br /> �` <br /> Application Accepted By� � Date� <br /> Additional Comments: <br /> hase 11 Gr ut Inspection �/J/� Phase II na 1 spection <br /> Inspection By Date,��.i�r� r Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE*! 0 EACH El January 1 R Received By January 3 ❑ July 1 &Received y July 31 <br /> REMIT <br /> BASE ;EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE !j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �-� 3 55 1 e I <br /> Received by I Date 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 STOCKTON,CA 95261 <br />