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_ "'Applications,Will Be Processed When Submitted Properly Completed. Be Sure <br /> _To Sign The Application. <br /> [FOR ar._ E USE: APPLICATION- (j } <br /> (For Non-Transferable, Revocable, Suspendable) <br /> i - PUMP&WELL �1 1 <br /> 'ENVIRONMENTAL HEALTH PERMIT . <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is IN <br /> made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County O dinance NP. 1862 aW the Wles and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 64 City/Town <br /> Owner's Name G,f R U Phone <br /> Address City `'� <br /> Contractor's Name License tf /�! Business Phone T��� 767 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation sur �on �WithSJLHD? Yes No <br /> TYPE OF WORE( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy v <br /> Sewage Disposal Field Cesspool/Seepage Pit Other d,� <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> PLINDUSTRIAL 0 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 .�,,,WS4yApV.,SeaI Install <br /> PUMP INSTALLATION: Contracto <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br />`- DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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 /> I <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 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 for which this <br /> permit is isued , I shall employ persons subject to workman's compensation laws of California." <br /> I will call for Grout Inspectio for groutin and inal inspection. X_h� <br /> Signed itle: Date: <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase I Final spection <br /> Inspection By Date Inspection By := Date1Q <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31.- <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I7 91a /CJ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA- 901 r <br />