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Applications Will Be Processed When Submitted Properly Completed. a SureTo <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit���oaquiCou y Ordinance No. 1862 and the rules and regulations of the San Joaquin L cal Health District. <br /> City/Town -} <br /> Exact Site Address • <br /> s <br /> Phone <br /> Owner's Nam =` �.��,.� ��� +� <br /> Address City�,� p <br /> license# d� �S� usiness Phone <br /> Contractor's Name �W _ Q� <br /> Contractor's Addres J ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No I <br /> TYPE OF WORK (CHECK): NEW WELL 9Y DEEPEN ❑ RECONDITION ElDESTRUCTION❑ w <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C3OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> I DISTANCE TO NEAREST: Septic Tank es Pit Privy <br /> `—'tT Sealer Liny <br /> Sewage Disposal Heil <br /> Cesspool/S� Other <br /> page Pit ^— <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ D1/0 <br /> USTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> 11� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC C3 DRIVEN <br /> Gauge of Casing j <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout S { <br /> ❑ CATHODIC PROTECTION ROTARY. Type of Grout r <br /> II ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 444 PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11 State Work Done --� <br /> Well Diameter Approximate Depth ! _ <br /> DESTRUCTION OF WELL: v` <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. <br /> Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit <br /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f 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 emplo ersons subject to workman's compensation laws of California." <br /> will call for a Gro ti n prr r to grouting and a final inspection. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 0®� Date <br /> Application Accepted By �R�--� <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase !II Final Inspection <br /> Inspection By <br /> --'tart Date - V' Inspection By Date 1 <br /> y <br /> n <br /> Fee IS Due: ANNUALLY PER UNIT L) PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT L <br /> �- BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 6 � <br /> FEE <br /> k LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed Delivered <br /> Received by D to Receipt No. Permit No. <br /> ! 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 9 0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - <br />