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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureTo signTheApplication. <br /> FOR OFFICE USE:, APPLICATION <br /> r (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 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. 1862 and the rules and regulations-of the San J! Local Health trict. <br /> gag L41R <br /> I Exact Site Address � + City/Town <br /> Owner's Name � �� ` �� G 'i Phone <br /> Address Rip , {I e!5 0_CS City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address / Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on t=ile With S HD? Yes No ren <br /> ' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �! 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Cl PUMP INSTALLATION ❑ PUMP REPAIR❑ �f <br /> REPLACEMENT �S <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y Pit Privy <br /> Sewage Disposal Field _ -.Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE'.a ❑ DRILLED Dia. of WeII.Casing <br /> ❑ DOMESTIC/PUBLIC j ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONI , ❑ GRAVEL PACK Depth of Grout Seal <br /> r ❑ CATHODIC PROTECTION .I = ❑ ROTARY Type of Grout <br /> El ❑ OTHER ' Other Information s <br /> ❑ GEOPHYSICALSurface Seal I alled.B <br /> PUMP INSTALLATION: Contractor _p <br /> Type of Pump, H"P. f <br /> PUMP REPLACEMENT: ❑ State V1lork`Don& F 0 <br /> PUMP REPAIR: <br /> 11 State Work Done f v <br /> � , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> Describe- Material andyProcedure <br /> I hereby certify that JI 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this perg 4 <br /> is issued, I shall noE 1lemploy 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 worklorwhich this <br /> i permit is issued,I shall employ persons subject to workman's compensation laws of California"" <br /> I w'II call for a Grout Inspe n ri r to grou ing and a final inspection. /. � �^ <br /> C �!?s/" Date: c 1 l� <br /> Signed X J itle: - <br /> if <br /> (Draw Plan on Reverse Side) i <br /> 1 FOR DEPARTMENT SE ONLY <br /> PHASE ! { � " 6 <br /> Application Accepted Byi date <br /> Additional Comments_: <br /> Phase It Grout Inspection ,r.. �. h sePI Final Inspection <br /> �. Inspec46 <br /> tion "', Inspection By Date Ins p By Date <br /> Fee Is Due: 11 ANNUALLY'' ❑ PER UNIT W PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE 7 <br /> LESS <br /> PRORATIONPLUS <br /> } <br /> PENALTY ,4 <br /> { OTHER <br /> OTHER " 03 <br /> Received by Date Receipt No Permit No. Issu nce Dae Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES To: EN IRONMENTAL HEALTH PERMIT/SERVICES 1601 E`HAZELTON AVE.,P.O Box 2909 STOCKTON, 1 <br />