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Applications Will Be Processed When Submitted ProperlyCompleted. Be SureToSignTneAppucallon. j <br /> JsE: APPLICATION <br /> _. (For Non-Transferable, Revocable, Suspendable) 1 <br /> PUMP&WELL { <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 w h San i4quin County finance No. 1862 and th rules and regulations of the San Joaquin Lo al HeELIth District. <br /> Exact Site Address Ll i2 t I 's City/Town - <br /> Owner's Namery) Phone <br /> Address 3 L Cept L City <br /> Contractor's Name License# _ Bu iness Phonev2 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes '� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATE ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION Nr PUMP REPAIR El =; <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy tA o <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ; <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 Bone <br /> 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. m <br /> Homeowner or licensed agent's signature certifies the following:A certify that in the performance of thework forwhich 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 1he following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ perso subje to wo n's compensation laws of California." <br /> call r a Grout in pection r to g uting a In inspection. <br /> Signed _ aw Date: <br /> (Draw Plot Plan on Reverse Side) <br />�. FOR DEPARTMENT USE ONLY <br /> PHASE I - 0,: <br /> Application Accepted By Date V <br />( Additional Comments: Af <br /> k Phase II Grout Inspection _ Pha�sj III Final Inspection <br /> PV) � <br /> Inspection By , Date Inspection By 21 ti• - Date U <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> 'BASE EXPLANATION A <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> F` FEE 445 <br /> / <br /> LESS <br /> h PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> € Received by Date Receipt No. Permit No. Issuance Date ,- Maited Delivered <br /> (. -. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />