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FOR OFFICE USE: APPLICATION <br /> f=or Non-Transferable, Revocable,Suspendable),,,w <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> COMPLETE IN TRIPLICATE) 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 ewiith San JoaquiinlCou ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> _xact Site Address�t��� !Vc rT1 �c �' 01 City/Town <br /> "owner's Name Phoneq 4 <br /> Address city L !� <br /> :ontractor's Name License tLS � Business Phone's 174< �� <br /> ontractor's Address C —V:,—+p i Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> 'YPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> VELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank IIb Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f.� <br /> Cl-IRRIGATION GRAVEL PACK Depth of Grout Seal Z. <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout t"P_m <br /> -4D DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> SUMP INSTALLATION: Contractor <br /> Type of Pump 81• Q_ H.P. 'a A <br /> PUMP REPLACEMENT: ❑ State Work Done —� <br /> DUMP 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:"1 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 calll for a Grout I �e Ilion prior tg grouting and a final inspection. <br /> ''n J <br /> Signed X jX � Title: /QLD ci Date: l� <br /> .� (Draw Plot Plan on Reverse Side) <br /> FO DEPA ENT USE ONLY <br /> PHASE I 79 <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection / Phase III Final Inspection <br /> .� Inspection By %' ' Date /05 Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o O <br /> i_ Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ADDI Ir`ANT—RFTI IRN AI I COPIFS TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />