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Applications Will Be Processed When Submitted Properly Completed,Be Sure To Sign The Application. <br /> FOR oFFlce SE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 /> lade in compliance with San Joaquin County Ordinance No. 1862 andAlejules and regulations of the San Joa uin L aI Health District. <br /> Exact Site Address <br /> City/Town <br /> Owner's Name yl.Mr 361E=3QQ <br /> Address ------ Phone._ <br /> Contractor's Name <br /> License it_- Business Phone <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD?Emergency <br /> No <br /> Phone _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ I <br /> "DISTANCE TO NEAREST. Septic Tank _ Sewer Linesa <br /> Pit Privy <br /> Sewage Disposal Field_ Cesspool/Seepage Pit <br /> — OtherPro> rt Line _ Private Domestic , <br /> Well _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL ----'� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal v <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL 'J% <br /> Type of Grout -` <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: <br /> - _ <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P. <br /> ❑ State Work Done. <br /> PUMP REPAIR: State Work Done <br /> • zSTRUCTION OF WELL: Get 4 r <br /> Well Diameter-_ _ pproximate Depth �. <br /> .– Describe Material and Procedure <br /> 1 hereby certify that I haver red this - jj <br /> P s application and that the- work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rulleses 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 /> Contrac is hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> Permit issue I shall employ persons subject to wor s compensation laws of California." <br /> I will 11 for rout Inspection p ti d mal inspection. <br /> Signed X . <br /> file: -— LL11a�r _ Date: {J I <br /> (Draw Plot Plan on Reverse Side) — ; <br /> P SE <br /> F DEP RTMENT USE ONLY t <br /> Application Accepted By <br /> Additional Comments:__ Date . <br /> Phase fl Grout Inspection � <br /> Inspection By Date_ hase 111 Final Inspeeti <br /> Inspection B91", <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITf <br /> ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑JAI 1 g R <br /> BASE Y eceived BY July 31 <br /> EXPLANATION BILLING REMITTANCE $ REMIT <br /> GATE <br /> FEE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> LESS <br /> PRORATION .. <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER k <br /> a: <br /> _ e <br /> Red'ei ed by Dae -- <br /> i <br /> APPLICANT— 1 Receipt Permit NNoo <br /> No:` �• . =--t-- <br /> 1�RETURN ALL COPIES 70: ENVIRONMENTAf.HEALTM-PERMIT/SERVICES Iss"anr* 1e Mailed Delivered <br /> — <br /> liel E.HAZELTON AVE.,P.O.Boa 2009 <br /> ._ STOCKTOH,CA!1201 <br />