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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 with an Joaquin CountyOrr ance No. 1 2 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address [v 721 City/Town <br /> Owner's Name Phone <br /> Address + City <br /> Contractor's Name ` Licens y T Business <br /> Contractor's Address �� Emergency Phone / <br /> Is Certificate of Workman's Compensatio ns ranee on File With SJLHD? Yes No t <br /> TYPE OF WORT( (CHECK): NEW WELL DEEPEN ❑ RECONDITI -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL A AN ONMENT ❑ OTHE _ PUMP INSTALLATION UMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 'WalY 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 ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Z-H IGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER -eOther Information <br /> ❑ GEOPHYSICAL Surface-5ea1 Ins led By <br /> PUMP INSTALLATION: Contractor C� �� <br /> Type of Pump r H.P. <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 cal for a Grout Inspection prior to grou ' and a final inspection. <br /> Signed X + .,��. .�-t - � Title: gzfiC. --7e _ Date: � <br /> (Draw Plot Plan on Reverse Side) <br /> O FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Y o, CD' Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection /�¢ V ill Fin i Inspection <br /> Inspection By Date AIX Inspection By v" Date <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATF REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 42 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a`J 1 2 <br /> Received by Date Receipt No. Permit No. I uar Oate Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.1 2009 STOCKTON,CA 95201 <br />