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ly <br /> Applications Will Be Processed When SubA1mPPLjCArTIONpleiea t5e7ury rw <br /> FOR ar.��eE usE: � PUMP&WELL <br /> (For Non-Transferable,Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health District for a perm ltto construct and/or install the work herein described.This application I5 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> r Exact Site Address <br /> Phone ' <br /> ! Owner's Name <br /> City___ <br /> Address <br /> Business Phone l <br /> License <br /> Contractor's Name / <br /> Phone <br /> Contractor's Address_ �� q_T� ' " 0 Emergency <br /> N o <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> L� p � <br /> I TYPE OF WORK (CHECK WE WABA�T MENT 0❑ OTHER ITI PUMP INSTALLATIONON��PUMP REPAIR <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> cesspool/Seepage Pit Other <br /> t Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f/ <br /> 11INDUSTRIAL 11 CABLE TOOL Dia. of WelGauge of Casing Excavation <br /> Q I <br /> L�'1g5fVfESTIC/PRIVATE <br /> 13 DRILLED /Dia. of Well Casing s7 <br /> �. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Q P <br /> ❑ IRRIGATION r�.�� <br /> El GRAVEL PACK Depth of Grout Seal <br /> 13 CATHODIC CATHODIC PROTECTION l C I ARY Type of Grout <br /> ❑ DISPOSAL <br /> El OTHER Other Information <br /> dace Seal Installed By: <br /> 13 GEOPHYSICAL S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <br /> w <br /> + I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin oun y <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 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 for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grout! a d a final inspection. e <br /> Title: _T Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I —��— - —f3gte <br /> f Application Accepted By <br /> Additional Comments: <br /> Glia I11 Final Ins ction <br /> Phase 11 11 G ut Inspe 'on Date <br /> Inspection By. <br /> Date Inspection By <br /> �. Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 <br /> El 1 &Received R M17uly 33 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> IZ a1-9 a <br /> FEE / <br /> LESS <br /> PRORATION <br /> PWS <br /> PENALTY <br /> I <br /> I <br /> OTHERt <br /> OTHER15 519 <br /> Date Receipt No. Permit No. Issuance Date -Mailed Delivered <br /> Received by - 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTISEAYICES _ <br />