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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppllcanon. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL of <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> OMPLETE IN TRIPLICATE) <br /> (Cn ., .. <br /> al Health District a permit to construct an install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Loc <br /> made in compliance with San Joaquin County Ordnance o. 1862 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �' -� City/Town <br /> Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name License#�� Business Phone _ <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 E] DEEPEN 13RECONDITION❑ - DESTRUCTIONN❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT El OTHER El PUMP INSTALLATION W PUMP REPAIR© C> <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer tines 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 /> J; ]' 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 L- H.P. <br /> REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> 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. r <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, 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 the following:"I certify that in the performance of the work far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c r Grout inspection prior to grouting and a final inspection. <br /> ' Date: '_�CF `r <br /> Signed Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IRate <br /> //rte & <br /> r <br /> ;'Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph a anal inspection1'9 � <br /> Inspection"By <br /> Date Inspection By Date �p <br /> Fee Is Due: ❑ ANNUALLY ❑.PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION - -BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> ' PRORATION i - <br /> PLUS <br /> PENALTY t <br /> OTHER a. ; <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No, - I uance ate _ Mailed Delivered <br /> 1601 E- ZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />