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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 1f (For Non-Transferable, Revocable, Suspendable) <br /> F" PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance Ith San Joaquin County Ordinance No. 1 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address k V 21. t�'eL .TI�� City/Taw <br /> Owner's Name Phone 3 S� <br /> Address 4P11 .� Q_ City- <br /> - 74 , j <br /> Contractor's Name License# Business Phone 0 <br /> Contractor's Address � ( Emergency Phone X, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLS' DEEPEN ❑ RECONDITION 11 DESTRUCTION❑. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �� PUMP REPAIR <br /> REPLACEMENT❑ .1i ��� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Linew., Private Domestic Well_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <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 /> 1:1 GEOPHYSICAL Surface Seal Installed By: . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �Z <br /> PUMP REPLACEMENT: ❑ State Work Done <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, 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:"I 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 will call for a Grout spection prior to grouting and a final inspection. <br /> Signed X Title: - Date: �� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPA4; RT NT USE ONLY <br /> PHASE <br /> Application Accepted By Date /) 4(f, <br /> Additional Comments: <br /> Pha,e I Grout Ing ction (%� Pha III incl I pection <br /> Inspection By 1+� ^Date 419— `p Inspection By Date 6 iv <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT I XPER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> G tpllDD <br /> Rec ived by Date eceipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />