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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OFFICE USE:USE: APPLICATION' <br /> (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 Districtfora permit to construct and/or i nstallthework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address dho .L- �9,yLcil K_0 City/Town <br /> Owner's Name tl Phone <br /> Address I r zf 9z City <br /> Contractor's Name " License# Business Phone <br /> Contractor's Address ✓ a Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes Ar No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN, RECONDITION DESTRUCTION❑ 00 <br /> WELL CHLORINATION WELL ABANDONMENT © OTHER ❑ PUMP,INSTALLATION 19 PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 gia. 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 /> ❑ CATHODIC PROTECTION `❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Ins Iled By: <br /> PUMP INSTALLATION: Contractor V <br /> Type of Pump �� H.P. ?/ <br /> PUMP REPLACEMENT: ❑ State Work Dane PIC <br /> PUMP%FfA": State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure <br /> { <br /> 1 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 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 /> 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 w'I call for a Grout Ins ectio==Title: <br /> inal inspection. <br /> Signed X Date: / <br /> (Draw Plo Ian on Reverse Side) <br /> FOR EPART ENT USE ONLY <br /> PHASE I <br /> Application Accepted By �' Date f <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final spection <br /> Inspection By M 1& _ Date Inspection By ate q+S� <br /> ,tom <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 $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> 54 AMOUNT 1 <br /> p <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER d <br /> r <br /> OTHER <br /> Received by Date Receipt No. Permit No fssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - ,, <br />