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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br />' FOR OFFICE i��:,,w <br /> APPLICATION <br /> .. (For Non-Translerable, Revocable, Suspendable) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application.is <br /> made in compliance with San Joaquin ounty Ordinance No,1862 and the rules and regulations of the San Joaquin Local Health District. <br /> l Exact Site Address O - `--°^ City/Town <br /> I <br /> Owner's Name - Phone . _ <br /> l Address — ha-f-rte City-=� � p� <br /> Contractor's Name License#/4 �3 �3 Business Phone d — <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4-1 No ; <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT 1:1OTHER 1:1PUMP INSTALLATION 13PUMP REPAIR c� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer,Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private DomesfioWell Public Domestic Well <br /> INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well,Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Welli Casing <br /> 1 C1DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑_CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑-DISPOSAL ElOTHER Other Information # <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 0 <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump � � <br /> PUMP REPLACEMENT: 13 State-Work Doney <br /> 1 11101, <br /> PUMP REPAIR:, �State'Work Done <br /> DESTRUCTION'OF WELL: Well Diameter Approximate Depth- <br /> Describe Material and Procedure s '1 <br /> I hereby certify that I have prepared this-.application and that the work-will tie 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 forwhich this permit <br /> is issueI d, 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 /> 1 Ica for a Grout spection prior to outing and a final ins ection. <br /> Signed X <br /> Title: Date: � <br /> (Draw Plo Pari on Reve a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pas III Final Inspection <br /> Inspection By Date Inspection By �✓ Date 3G <br /> f <br /> k Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t 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 /■ 1 _� - <br /> lpate Receipt No. ,mit No. su nce Dae Mai$ed Delivered <br /> Received by ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL ° <br /> HEALTH PERMITISERVICES 1 1 E.HAZELTON AYE.,P.O.Bok 2009 STOCKTON,CA 95201 <br />