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& Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ';,FOR OFFICE USE: APPLICATION <br /> i (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <<: <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> t (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 an Joa if Co�'nt Ordinance No. 1862 and the rules and regulations of the San Jo�uin Loa Health District. <br /> Exact Site Address ��m I'd a� g City/Town 5' <br /> Owner's Name L` Phone <br /> Address9 ' City <br /> Contractor's Name License J42VAP Busines Phone " Z <br /> Contractor's Address — dt- 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❑ DESTRUCTIONR <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 /> I <br /> Property Line Private Domestic Well Public Domestic Well <br /> 3 INTENDED USE TYPE OF WELL <br /> I: ❑ 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 Depth of Grout Seal <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> y ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done. <br /> PUMP REPAIR: ❑ State Work Done <br /> F DESTRUCTION OF WELL: Well Diameter `�� Approximate Depth <br /> De cr'be MateriahqaQd Procedure <br /> I hereby certify that I have prepared this application and that the work will a done in ccordance wl San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 persons subject to workman's compensation laws of California." <br /> I will call for a�G speclio�nrior I grouting and a final inspection.Signed X <br /> Title,Va/� �� Date OC/ <br /> (D raw <br /> an on Reverse Side) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASEI t <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P ase III I nal Inspection <br /> Inspection By Date Inspection By Date ! "y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $i. - BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE ECKED <br /> € AMOUNT <br /> FEE 01 430 <br /> LESS <br /> I PRORATION <br /> t PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt-No. Permit No x 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 /> F <br />