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`.cations Will Be Processed When Submitted Properly Completed. Be SureSAn <br /> r �r APPLICATION pplication. <br /> (For Non-Transferable Revocable <br /> PUMP&WELL. <br /> ir ENVIRONMENTAL HE RMIT �g�� <br /> (COMPLETE IN TRIPLICATE) WATER QUALIT SSP 1 L <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or instal <br /> 1pr�c. in described,This application is <br /> made in compliance with SaIR Joaquin County Ordinance No. 1862 a the rules and reg ulat'otnsh �v Lin Disfrict. <br /> Exact Site Address 1 1-1 <br /> Owner's Na �Z D �� � - <br /> Address ) 5 p� Phone <br /> a <br /> City 1 <br /> Contractor's NameLicense Business Phone <br /> Contractor's Address Emergency Phone Q ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> r. TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11-' PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I REPLACEMENT❑ C� <br /> 3 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy OOl <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL d <br /> ❑ 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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ 7 <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter AApProxl to <br /> Describe Material and Procedure <br /> a <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 thework 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 /> ContraFto r'sPwW or sub-contract'n signature certifies the following:"I cer that in the performance of the work for which this <br /> per U shall employ p rso subject to workman's compen laws of California." I <br /> I ill c nspection 'rior t grouti and a final inspecti ,l <br /> Signed X � Title: Date: <br /> (Draw Plot Plan-on Reverse Side) -- �- -� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ' <br /> Application Accepted By- f Date <br /> Additional Comments: 1 <br /> Phase II Grout Inspection4as I_Finai speclion l <br /> Inspection By Date Inspection B ate <br /> Fee Is Due: El ANNUALLY El PER UNIT 13 PER SITE El EACH ❑ January 1 &Received By Janu y 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> PATE DATE REMITTEDf <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ` AMOUNT <br /> FEE � / S C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No-r issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,CA 95201 ' <br />