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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, Revoeable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT /-6 7--1 <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 /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the-San Joaquin Local Health District. <br /> Exact Site Address OS City/Town <br /> Owner's Name r ,• a, _ — Phone.? `�� -.� f <br /> Address �z 7—IiF City <br /> Contractor's Name r��a-�r "` License Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r_�r No <br /> TYPE'OF'WORK (CHECK): NEW WELL-El— DEEPEN ❑ RECONDITION DESTRUCTION❑ --- — -WELL CHLORINATION ❑ -.-WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Z----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 TYPE OF WELL <br /> ❑, IND STRIAL M ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC i ❑ DRIVEN Gauge of Casing ` <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grou$ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _. <br /> PUMP REPLACEMENT:. ❑ State Work Do e <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 San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> -t I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date:_ I—GO <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � t. � r� <br /> Application Accepted By Date D <br /> Additional Comments: <br /> Phase It,Grout Inspection PhI Final Inspection <br /> Inspection By Date Inspection.By r Date <br /> Fee Is Due: ❑ ANNUALLY'- ❑ PER-UNIT ❑ PER SITE .'❑ EACH " '❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE REMIT <br /> ' $ ' <br /> " EXPLANATION BILLING, REMITTANCE.DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ---- – AMOUNT <br /> FEE �$ <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER'.. .'..- _ .x .T..._ -. - - i - - •- - <br /> OTHER <br /> _ ¢ : 4 3� <br /> Received by <br /> Date, �_ Receipt No. .Permit No.. ssuance Pate. Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201LL <br />