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Applications Will Be Processed When-Submitted Properly mpleted. Be Sure To Sign The Application. k <br /> FOR,OFFICE USE: / APPLICATION66"LPXZA (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY y <br /> istrictfora per.mitto constructand/or thework herein described.This application is <br /> Application is hereby madeto the San Joaquin Local Health D <br /> made in compliance with San Joaquin County Ord'nance No. 1862 and the rules and regulations of the San Joaquin Local Health District" <br /> Exact Site Address (>3 !V /! City/Town <br /> Owner's Name ✓ Phone <br /> City—C <br /> Address O / — <br /> s�Business Phone 6' e <br /> Contractor's Name License #� _� <br /> Contractor's Address OA Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER 11PUMP INSTALLATION 11 PUMP REPAIR❑ l 1 <br /> I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field " Cesspool/Seepage Pit Other— <br /> Property <br /> ther Property Line Private Domestic Well Public Domestic Well — <br /> INTENDED USE TYPE OF WELL w <br /> r <br /> 1:1 CABLE TOOL Dia. of Well Excavation ; <br /> 11 INDUSTRIAL rr <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing it <br /> ❑t DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> pa IRRIGATION ❑ GRAVEL PACK k Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY' Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Se�stalled By: <br /> PUMP INSTALLATION: Contractor 0 <br /> Type of Pump 7 H.P. C3 <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 /> C9 <br /> ~ 1 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 aiiy person in such manner as to become subject to workman's compensation laws of California." <br /> I' 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." C <br /> II I ilvy I call for a Grout Inspe 'on rior o gro nand a final inspection. <br /> Signed �I'p itle: Date: - <br /> (Draw Plot an on Reverse Side) <br /> O <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I .O1Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase If Grout inspection asg I I Inspection f(jp <br /> Inspection 13y Date Inspection By a TU <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT <br /> BASE EXPLANATION BILLING REMITTANCE 5 _ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE A# <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ' Received by - Date Receipt No. Permit No. _ Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ TON AVE„P.O:Box'2009, STOCKTON,CA 95201 <br />