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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> .j (For Non-Transferable, Rerocable,'Suspendable) ii"" PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to constructand/or install thework hereip described.This application is <br /> F: <br /> made in compliance with San Joaquin Co y Ordinance No. 1862 andthe rules and regulations of the San JLQagain Local Health'District. <br /> Exact Site Address City/Town , <br /> Owner's Name Phone 6,Address � �'�- City <br /> Contractor's Name ��C_4� License Business Phon <br /> Contractor's Address _ �6, 's� �' Emergency Phone f' <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 CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0-- PUMP REPAIR <br /> REPLACEMENT❑ <br /> r - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy l <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 /> MESTIC/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 C Surface Se I Installed By: <br /> PUMP INSTALLATION: Contractor? <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dorg <br /> PUMP REPAIR: ❑ State Work Dane <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 thework forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca"V Grout Ins on.prior to grouting and a final inspection. ' <br /> g _ Z( �( <br /> Signed Title: sit--�-�'�� Date:l <br /> (Draw Plot Plan on Reverse Side) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By 1 `14. Date 1 <br /> Additional Comments: <br /> Phase II Grout Inspection's Phas� III Final Inspection <br /> Inspection By Date Inspection By /fit W' Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivetl by Date Receipt No. Permit No. Iss ane Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />