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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE..USE: I! APPLICATION <br /> ' (For� Non-Transferable, Revocable, Suspendabie) PUMP&WELL <br /> = ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> 4 made in compliance with.San Joaquin County Ordinance No. 1862 nd the rules nd regulations of the San Joaquin Loca! Health District. <br /> I City/Town <br /> f <br /> Exact Site Address <br /> Owner's Name <br /> Phone - - � <br /> 1` Address City <br /> I Contractor's Name cc se#YC4� 7' Business Phone_ Z ^Z7dj7 - <br /> Contractor's Address h Emergency Phone 1 1^1_Zp zg/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 13 RECONDITION ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER PUMP INSTALLATION ❑ 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 Is TYPE OF WELL <br /> Et ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> t ❑ DOMESTIC/PRIVATEII 11DRILLED Dia. of Well Casing <br /> 1 13DOMESTIC/PUBLIC !I ❑ DRIVEN Gauge of Casing p <br /> ❑ IRRIGATION ji ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ij ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seat Installed By: <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H.P. 1 <br /> G.. <br /> PUMP REPLACEMENT: IJ 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 I.have prepared this application and that the work will be done in accordance with San7Joaquuinnty <br /> ordinances, state laws, andrules and regulations of the San Joaquin Local Health District. <br /> Home owner orlicensed agent's signature certifies thefollowing:"I certifythat in the performance of the work for which tspermit <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:i <br /> 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 wil <br /> III Groutllns ection prior to grouting and a final inspection:—, <br /> } Signed X s Title: Date: 7—,W - <br /> f ;� (Draw Plot Plan on Reverse Side) <br /> k ° FOR DEPARTMENT USE ONLY <br /> PHASE 1 I� 5 r Z J <br /> Application Accepted By Date <br /> it � . } � .` <br /> Additional Comments: - <br /> Phase II Grout inspection Pha a Ill nspection <br /> Inspection By Ij Date Inspection By Date O <br /> Fee Is Due: ❑ ANNUALLY Vis. El PER UNITPER SITE ❑ EACH ❑ January 1 &Received By Sanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION DATE <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> :I <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS II <br /> PENALTY <br /> OTHER { <br /> OTHER - <br /> 3 SS <br /> - Received by Date Receipt No. Permit No lissuande Date Mailed D6!ivered <br /> APPLICANT—RETURN—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> LI <br />