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f Appli gations Will Be Processed 6i ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: ' `-° n <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> SAN j-OAQUIN LGIRMONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)HEAL-fH D'S71 R1CT 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. J862.and the r les nd regulations of the San Jo n Local.Heap IDistrict. _ <br /> Exact Site Address T City/Town <br /> Owner's Name I � '' �'�!T Phone <br /> Address # / G� " City <br /> Contractor's Name t / License#. 7/�/c Business Phone <br /> Contractor's Address 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 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'.Wel[7 Public Domestic Well — <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK µ Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL _ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL D, &c Sufface Seal Installed By: <br /> PUMP INSTALLATION: Contractor + :._C A� <br /> Type of Pump ;] . - 6 H.P.' <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> Homeowner or licensed agent's signature certifies the following:"I certifykthat 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 orsub-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 /> 1 lcall or a Gro nspec'on prior to grouting and a final inspection. <br /> Signed X Title: bate: <br /> Y. * . (Draw Plot Plan on Reverse Side) E T <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE 1 r-e_O�a�ij Date 3� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 rout Inspection se III Final Inspection , <br /> Inspection By � Date Inspection By Date <br /> t <br /> Fee Is Due: ❑ ANNUALLY_r ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received'By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED <br /> �✓ C.� ' AMOUNT <br /> FEE J IS. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> -- <br /> OTHER <br /> OTHER <br /> Rrllceived 67y - - Date - - Receipt No. Permit No, Issuance Date - Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />