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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joac�u'In County Ordinan a No. 18,62 and the rules and regulations of the San Joaquin Local Health District. 1 <br /> Exact Site Address <br /> f 4 1�!— Gk-0 City/Town °(�a <br /> Owner's Name s [ Phone <br /> Address -2,V ! City <br /> Contractor's Name I License# 3, f Business Phone— l <br /> Contractor's Address 00 Emergency Phone <br /> Is Certificate of Workman's Compensation Rsurance on File With 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 Q Sewer Lines 1�0_ Pit Privy � <br /> Sewage Disposal Field Cesspool/Seepage.Pit _ Other <br /> Property Liner Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ! if <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation—�_� : <br /> +DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing61 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing .... s <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout t Q <br /> II <br /> 11 DISPOSAL 11 OTHER Other Information p <br /> ❑ GEOPHYSICAL Surface Seal Installed By: bei <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F <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 persons subject to workman's compensation laws of California." <br /> I will c or a Grout Inspec ion prior to grouting and a final inspection. <br /> Signed X Titter- ®��`�^•(r, Date: <br /> ( aw Pfot Plan on Reverse Side) <br /> i <br /> F DEP RTMENT USE ONLY <br /> 4 PHASE �Y <br /> k � Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Final Inspection <br /> Inspection By Date Inspection B ate v'- <br /> t 7°) }1,0 - �, <br /> Fee Is Dile: 13 ANNUALLY � ❑ PER UNIT El PER SITE ❑ EACH anu y 1 &Received nuary 31 ❑ July 1 &Received By July 31 <br /> + REMIT <br /> BASE EXPLANATI N BILLING REMITTANCE $ .AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 'LESS 4 <br /> PRORATION <br /> f PLUS ! <br /> PENALTY <br /> I <br /> OTHER <br /> r <br /> OTHER..;. . . Z' <br /> Received by Date Receipt No. Permit No. lisuarice 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 />