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•�'� Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign TheApplication. <br /> 't OR'OF�ICE USE: <br /> APPLICATION IS <br /> v (For Non-Transferable, Revocable, Suspendable) <br /> � PUMP&WELL <br /> _ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER Qii11L1TY J <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is IJI s <br /> made in compliance with Sa Joa uin County Or nance No. 1862 and a rules and regulations of the San Joa of l H�ala�District. <br /> Exact Site Address �e? City/Town !r } <br /> Phone <br /> Owner's Name <br /> City <br /> Address � <br /> Contractor's Name 'lNt �nse Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Ice on File With SJLHD? Yes No _ I <br /> TYPE OF WORK (CHECK): NEW WELLnsura�DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ A <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines Pit Privy <br /> Cesspool e Pit Other a <br /> Sewage Disposal Field � p /Seepage <br /> Property Line- Private Domestic Well !�_140 r- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> "OMESTIC/PRIVATE ❑�DRILLED Dia. of Well Casing <br /> C] DOMESTIC/PUBLIC 9-DRIVEN Gauge of Casing <br /> ❑ IRRIGAT O I N ElGRAVEL PACK Depth of Grout Seat t - <br /> ❑ CATHODIC PROTECTION VROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �, <br /> PUMP INSTALLATION: Contractor n <br /> Type of Pump H.P. <br /> f <br /> j PUMP REPLACEMENT: ❑ State Work Done <br /> j 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work tor 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 certllies the following:"I certify that in the performance of the work far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wl f r a G n ction prior to grouting and a Lina! inspection. <br /> Signed X file-. Date: <br /> 4 (Draw Plot Plan on Rev se Side) <br /> I <br /> F R DEPARTMENT USE ONLY <br /> 4 PHASE 1 _. �j' <br /> Application Accepted B Dat"21- <br /> f <br /> Additional Comments: <br /> Phase 14 Grout Inspection]1 Ph;e 411 Final Ins ection*7/&— <br /> UALLY <br /> Inspection By ' Date Lr��Bd Inspection fay 1 DateFee Is DUE: ❑ ANN ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received EN By 31 <br /> ` - -- <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> f DATE DATE REMITTED AMOUNT <br /> FEE *4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> FF OTHER <br /> OTHER <br /> ` Received by -Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA$5201 <br />