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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> r=OR`OFFtCE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY °t1 1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein.descrlbed.This application is <br /> 11 o � w <br /> made in compliance with San Joaquin.County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> Ii�� Y�IQ�1 <br /> Exact Site Address City/Town�� �l—�-, r <br /> Owner's Namer.:r Phone > <br /> Address <br /> Contractor's Name r' License# 360fe _�2Business.Phone <br /> j Contractor's Address Emergency Phone` r . <br /> I <br />` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 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 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> j ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout n <br /> I ❑ DISPOSAL ❑ OTHER Other Information `\ <br /> I ❑ GEOPHYSICAL # Surface Seal Installed Bye' N <br /> PUMP INSTALLATION: Contractor ` <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done (,t <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, stale laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 for which this <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." ' <br /> I I will call for a Grout Inspection nor to grouting and a final inspection. <br /> Signed X t— Title: bate: � <br /> — -�'„� �� 7 — <br /> ( w Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I 01 ����J <br /> Application Accepted By irn bate <br /> t <br /> Additional Comments: <br /> MA <br /> II Grout Inspection ase RI Inspection <br /> Inspection By Date - Inspection By - l ' <br /> Fee Is Due: [TANNUALLY ❑"PER'UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31'« ❑ July 1 &Received By July 31 <br /> REMIT <br /> t <br /> BASE" Ex PLANATION 'BILLING REMITTANCE _ $ <br /> AMOUNT DUE- CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE <br /> LESS T <br /> ` PRORATION _ <br /> PLUS <br /> PENALTY <br /> #. OTHER <br /> OTHER <br /> ^ 1 I-0 14 <br /> Received by ­Date - Receipt-No.- :Permit No. 1 Issuance Date Mailed Delivered <br /> - - <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />