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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application.LL m <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application.is 1 <br /> made in compliance with San Joaquin County Ordi ance No. 1862 d the rules and regulations of the San Joaqu' ocal Health District. <br /> Exact Site Address City/Town } <br /> Owner's Name . Phone67 <br /> Address City �g q. . d <br /> Contractor's Name License# Business Phone l <br /> Contractor's Address � 3 S� ry "'CEmergency Phone f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN El RECONDITION 13 bESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E] PUMP REPAIR❑ I <br /> REPLACEMENT"❑ � � <br /> DISTANCE TO NEAREST: Septic Tank �—_� S�er Lines �(�. Pit Privy <br /> Sewage Disposal F[eId 1Q _ Cesspool/Seepage Pit �� Other <br /> Property Line/Q_$ Private Domestic Well . Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIALel <br /> CABLE TOOL Dia. of Well Excavation �® <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 <br /> AIRRIGATION El GRAVEL PACK Depth of Grout SealVV <br /> i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 f <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 for which this permit f <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-contractings'gnature certifies the following:"I certify that in the performance of the work for which this i <br /> permit is issued, I shall a loy pers s subject to workman's compensation laws of California." <br /> I wII for a oui 1 cti ,p ' ng and a final inspection. <br /> Signed X _ Title: I <br /> Date: <br /> (Draw Plot Plan on Revers de) <br /> l FOR DEPARTMENT SE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: Date �r I. <br /> Phase II Grout Inspection 1 Final Inspection <br /> Inspection By Date Inspection B Date <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R ived By January 31 ❑ July 1 &Received By July 31 ! <br /> BILLING REMITTANCE $ REMIT 111 <br /> BASE EXPLANATION 'AMOUNT DUE CHECKED <br /> ATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> ;i <br /> OTHER <br /> Received by Date Receipt No. Permit No. Vssuance Date Maiie—Delivered <br /> APPLICANT—RETURN ALL COPIES TO!_ ENVIRONMENTAL HEALTH PERMIT/SERVICES '. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />