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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-Transferable, Revocable,Suspendable) PUMP&WELL <br /> t ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 1 WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora pe.rmitto construct and/or Install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinan e No_,4862 an the rules-and regulations of the San Jo quin Local Health District. <br /> Exact Site Address City/Town <br /> All <br /> Owner's Name Phone <br /> Address v' City ` ' <br /> kContractor's Name . ` License# � � �,"Bu n ss PAione <br /> Contractor's Address h' P 'Emergency Phone:' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OFWORK (CHECK): NEW WELL©' DEEPEN❑ RECONDITION-❑ DESTRUCTION❑ - —" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP.INSTALLATION ❑ PUMP REPAItJV <br /> t REPLACEMENT 11, <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 - e <br /> © INDUSTRIAL 13-CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing , <br /> DOMESTIC/Pt PUC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION- .� 13-GRAVEL PACK Depth.of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information } " <br /> ❑ GEOPHYSICAL _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ' x Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done - Of ' <br /> PUMP REPAIR: State Work Done ' <br /> DESTRUCTION 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> 4 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 will call fora Gro t Inspection prior to grouting and a final inspection. <br /> Signed X:. Title: IaZZ Date: 3- t/ <br /> (Draw Plot Plan on R verse Side) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By r <br /> Date A <br /> Additional Comments: <br /> " I Phase II Grout Inspection i 4 *asellInspectioInspection By Date - s - Inspection BDater <br /> I <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 /> BASE; EXPLANATION .'BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED. AMOUNT <br /> FEE '(45 _ <br /> - LESS ; <br /> PRORATION <br /> PLUS n J r <br /> PENALTY <br /> OTHER. <br /> t OTHER <br /> A% <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 />