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Applications Will Be Processed When Submitted Properly Completed.Be SureTobign� <br /> APPLICATION <br /> =TEIN <br /> /J <br /> CL9Y►���� (For Non-Transferable,_Revocable, Suspendabie) PUMP&WELL U <br /> t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY y ,.. . <br /> ATE) <br /> Application is hereby madeto the San Joaquin Local Health District fora perrnit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ounty Ord' once No..1862 andit e,rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's-Name 1 , City ,r, „ <br /> 3 Address ; <br /> 1 ,�" License# Business Phone,�'o� <br /> Contractor's Name � ;g <br /> Contractor's Address Grp? � � - � '�" �tEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File. ith SJLHD? Yes No _ mr <br /> -DEEPEN <br /> ` TYPE OF WORK (CHECK): WELL/ABAELL❑NDONMENT ❑❑ OTHRECONDITION <br /> ❑ PUMP INSTALLATION 91 PUMP REPAIR <br /> WELL CHLORINATION <br /> REPLACEMENT❑ 4 <br /> Sewer Lines Pit Privy _ �I <br /> DISTANCE TO NEAREST: Septic Tank C74 <br /> Sewage Disposal Field #Cesspool/Seepage Pit Other <br /> j Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 01 I. DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION x— -❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor 6'� <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: x QrState Work Done <br /> ❑ State Work Done <br /> PUMP REPAIR: — Approximate Depth <br /> f DESTRUCTION OF WELL: E Well Diameter <br /> Describe Material and Procedure <br /> f <br /> 1 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 Joaq1.uin 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 /> F is issued, I shall not employ any person manner as to become subject to workman's compensation laws of California." <br /> fy that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the following:'I certi <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w I call for Grout Inspecti ri r t grow �a d a' Ia1 lnspe tion, f <br /> If Date-. l <br /> Signed X tk` e: <br /> (Draw Plot P On Reverse Side) <br /> FOR DEPARTMENT USE ONLY 7a- <br /> .Application <br /> PHASE 1 Date Accepted By <br /> Additional Comments' <br /> i' Phase 11 Grout inspection Phase Ill Final Inspection <br /> Inspection By <br /> Date Inspection By ate <br /> Fee IS <br /> Due: ❑ ANNUALLY C] PER UNIT PER SITE ❑ EACH ❑ January 1 &Received Ry January 31 ❑ July t &Received EBIylTuly 3i <br /> - BILLING REMITTANCE , .. $ - AMOUNT DUE .CHECKED <br /> - - BASE t EXPLANATION DATE DATE REMITTED AMOUNT , <br /> FEE <br /> LESS <br /> PRORATION <br /> A _I <br /> PLUS- # - - <br /> PENALTY — <br /> OTHER <br /> C OTHER _ <br /> 4 r <br /> Received by - "Date Receipt No. <br /> Permit No. — Is uan a Date Mailed Delivered <br /> ti APPLICANT—RETUflN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2004 5TOCKTON,CA 85201 <br />