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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable, Revocable, Suspendable) PLUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT �3 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name �►.-�-- K] _ Phone 2-� <br /> Address — City ��/ <br /> Contractor's Name License Business Phone g �� � <br /> Contractor's Address Emergency Phone <br /> Is Certificate!of Workman's Compensation Insurance on File With SJLHD? Yes No I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR n <br /> REPLACEMENT❑ �J <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 ❑ DRILLED Dia. of Well Casing <br /> RISOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 0 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL s Surface Seal Installed By: r� <br /> PUMP INSTALLATION: contractor �� w <br /> Type of Pump H.P. It <br /> PUMP REPLACEMENT: ❑ State Work Done, ux"� —I.— 044%e&!!! <br /> UMP REPAIR: ❑ State Work Done IF I <br /> DESTRUCTIION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> //I wil III fpr a Grout Insp ction prior to grouting and a final inspection. <br /> Signed )CCS 1 Title: tT71J1^-Q� Date:s+ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPAFj,TMENT USE ONLY <br /> PHASE I / !/'�// <br /> Application Accepted By _5 Date <br /> Date — �� <br /> Additional Comments: <br /> Phase II Grout inspectionPha I al Inspection <br /> inspection By Date Inspection By ✓ Date <br /> 10 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 Vl <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3- C1S 3 <br /> Received by Date Receipt No. Permit No. Is1suanc4 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 />