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Applications Will Be Processed When Submitted ProperlyCompleted. ue Sure Iosign 1newppluatwn. <br /> FOR OFFICE USE: APPLICATION <br /> t (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 San Joaquin Count dinance No. 1862 and the rulesAnd regulations of the San Joaquin Local Health District. <br /> Exact Site Addres City/Townb.r <br /> r Phone <br /> ~Owner's Name <br /> 277 <br /> Address City `1 <br /> Contractor's Name f3 License#�p- rj�� 3usiness Phone ` r <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes No j <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> 11 OTHER 11 PUMP INSTALLATION El PUMP REPAIR❑ <br /> REPLACEMENT*- <br /> DISTANCE TO NEAREST: Septic Tank 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 /> ❑ IRRIGAT,ION , - ❑ GRAVEL.PACK Depth of Grout Seal <br /> ❑ CATHODIC'PROTECTION= -.gin" ❑ ROTARY... Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:- +Contractor d-,r o. <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 <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> x ordinances, stale 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, l 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 issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout In tion prior to routing and a final Insp P <br /> tion. <br /> Signed XTitle Date: ff <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPARTMENT USE ONLY r, <br /> PHASE I Date',x��� f <br /> � Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection se 1 nal Ins coon <br /> Inspection By Date A"t <br /> Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EJ(PLANATIpN BILLING $ AMOUNT DUE CHECKED <br /> GATE MITTED AMOUNT . <br /> F <br /> FEE C1D <br /> LESS <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 44 <br /> q r� 79 <br /> Received by Date Receipt No. Pe�rrnif No I Issu rice Date Mailed Deliv <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />