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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> F99-YFiCE USE: ` I APPLICATION 11 <br /> (For-Non-Transferable, Revocable,Suspendable) � <br /> -�� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 compliant with San Joa ui County Ordinan a No. 1862 and the rules and regulations of the Sa Jo quin oc I Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address — City (� <br /> Contractor's Name icense � Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No Ic <br /> rc <br /> TYPE OF WORK (CHECK): NEW WELL- DEEPEN 11RECONDITION ElDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ 1� <br /> DISTANCE TO NEAREST: Septic Tank # 70. Sewer Lines Pit Privy Mst-= <br /> Sewage Disposal Field Of Cesspool/Seepage Pit ,'(WA0 Other <br /> Property Line /�f Private Domestic Well 7- 11 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 392CABLE TOOL Dia. of Well Excavation <br /> .DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -- <br /> © IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL N Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a -4- S <br /> Type of Pump H.P. �.. <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> ,r <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 arab[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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Iwill 11 for a Grou I pection prior to-grouting and a final inspection. Q+/a /b <br /> Signed X Title: ! 1r� �1_ Date: E]{ SD <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By D <br /> Additional Comments: <br />' P a II Gr ut Inspection a III Fin I Inspection <br /> Inspection B Date IF~�8__< Inspection By Dafe/�— I -Bo <br /> Fee Is Due�ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE ITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> t� PLUS <br /> PENALTY y <br /> OTHER it <br /> OTHER L yl�v��lt <br /> - <br /> Received by Date Receipt No. Permit No. Issuance 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 />