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Applications tBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR�OFIE usE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -0 <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/orinstall thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rule 'Ind regulations of the San Jo uin cel Health District. <br /> Exact Site Address City/Town _ >r <br /> Owner's Na <br /> mePhone <br /> Address r <br /> City <br /> Contractor's Name Licensee" Business Phone 1 <br /> Contractor's Address Emergency Phone _3& 7 V z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Lam" No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ G <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 5-- PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tanker f Sewer Lines f Pit Privy r <br /> Sewage Disposal Fi d �Cy r Cesspool/Seepage Pit ?,w Other <br /> Property Line �.41vate Domestic Well�T-Public Domestic Well�� . _ <br /> INTENDED USE TYPE'OAF WELL 13yr�o�f PXfJ�t� AJ_e/l!,eG,} Gid cCf �j 0__ J <br /> ❑ INDUSTRIAL ❑ CABLE TOOLDia. of Well Excavation A <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Ilam . <br /> Dia:of Well Casing id <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1.2 [ <br /> ❑ IRRIGATION ❑ GRAVEL PACK', Depth of Grout Seal io l y <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout q <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL <br /> ' Surface Seal Instaile By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump e H.P. <br /> 1 <br /> PUMP REPLACEMENT: ❑ State Work Done ix <br /> PUMP REPAIR: ❑ State Work Done f <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth # <br /> Describe Material and Procedure 1 <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. 4e a <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the workjorwhich 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, 1 shall employ persons subject to workman's compensation laws of Cdlifornia." ' <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: <br /> ate: O <br /> D <br /> (Draw Plot Plan on Reverse Side) ' <br /> R <br /> =x <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE " <br /> Application Accepted By Date�Zl <br /> Additional Comments: <br /> Phase Ii Grout Inspection P Phase III Final Inspection <br /> Inspection Bydr3 Date, 219 9 Inspection By —?Date O <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 $ i REMIT <br /> BASE E?(PLANATfON AMOUNT DUE CHECKED <br /> DATE DATE REMITTED y AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER - <br /> Fs 1 -7 11 <br /> Received by Date Receipt No. yn Permit No. ' Issuance Date Mailed Deliver <br /> eg <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 t <br /> r <br />