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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 3 <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County`Or inan o.1862 ind,the rules and regulations of the San Jo uin Local Health District. <br /> Exact Site Address /V ` City/Town <br /> Owner's Name o /tL1 Phone <br /> Address City <br /> Contractor's Name License# 4 Business Phone ' <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensation Insuran a on Fileith 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 "/00 Privy i <br /> Sewage Disposal Field_ 10 v- /_ Cesspool/Seepage Pit Other <br /> Property Line 1._? Private Domestic Well Public Domestic Well <br /> INTENDED USE TYP OF WELL �/ <br /> ❑,,, INDUSTRIAL ABLE TOOL Dia. of Well Excavation <br /> C-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 2,0 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 5 Seal Insta ed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump HV <br /> PUMPREPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> n r <br /> DESTRUCTION OF WELL: Well Diameter Q Approximate Depth <br /> 570 <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 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 /> permit is issued, I shall employ per ons subject to workman's compensation laws of California." <br /> I will calllpr a Grout Inspectio or to oyting and a final inspeRMn. 2 <br /> Signed X Title: Date:42 �J• Z <br /> (Draw P of Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> e If Grout Inspection hase I i al Inspectlon h <br /> Inspection By f Date A Pi"r Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PATE REMITTED 0 Cl <br /> AMOUNT <br /> FEECIL C4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce 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 />