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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION ; <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTWOERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or i ristall the work hereindescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the'rules and regulations of the San Joaquin Local Health District. ,t <br /> Exact Site Address t. �3 City/Town�' <br /> Owner's Name ".R'.bPhone.. ' <br /> Address e �,� City <br /> Contractor's Name z1I +-'!-PLicense#" 3 - Business Phone, <br /> Contractor's Address>pU , 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-E) DESTRUCTION❑ <br /> PUMP REPAIR <br /> WELL CHLORINATION 11 WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 6; ❑ 1 <br /> _ a <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lfnes'l 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 /> ❑ tND STRIAE - CABLE TOOL Dia- of Well Excavation <br /> I OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> x <br /> ❑ bOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑.IRRIGATION `. ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ OTHER Other Inforination n.1 <br /> 11 DISPOSAL �., <br /> ❑ GEOPHYSICAL' Surface Seal Installed By: <br /> I . <br /> PUMP INSTALLATION: Contractor r H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> I PUMP REPAIR: I ❑ State Work Done <br /> F 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 C9permit <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 the work for which this is issued, I shall not employ any person in such manner.as to become subject to workman's compensation laws of Calif <br /> Contractor's hiring or sub-contracting signature certifie§the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation-laws of California." <br /> ' t <br /> = I will c 1 f a Grout In pection prior to grouting and a final.inspection. <br /> Signed X Title: —37'rC�`�_ <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> - i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' �lJ <br /> Application Accepted'By (� Date <br /> Additional Comments: ' <br /> 'Phase II Grout Inspectionall {hal Inspection <br /> Inspection By Date. Inspection By Dig <br /> !tit' <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS n <br /> PRORATION i <br /> PLUS - <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Received.by Date - Receipt No. Permit.No. I uanc .Date Mailed .- Delivered: <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERvIcES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />