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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �. <br /> FOR OFFICE USE: APPLICATION <br /> a - (For Non-Transferable, Revocable, Suspendable) PUMP&WELL J/ / <br /> ENVIRONMENTAL-HEALTH PERMIT 1/ " <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 Joaquin Local Health District, <br /> Exact Site Address l City/Town <br /> Owner's Name { ' Phone. {" <br /> Address yv CC, y . <br /> Contractor's Name S License#- Business Phoneme Z f G � <br /> Contrac'tor's Address W mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONSTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ p�+ <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 7 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION13 GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br />€ <br /> ❑ OTHER Other Information❑ DISPOSAL � ' <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION:_ Contractor m'' <br /> a <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT:`. " 'E] State Work Done— <br /> PUMP <br /> one PUMP REPAfR: Z1 State Work Done "r"� `~ �"�Ills <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 /> i <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 /> 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 call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed /1' eld <br /> Title: Da <br /> a Tot Plan on Revete:_ <br /> I rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI ' ` l 1 _ 0 ...—Q-) <br /> I Application Accepted By Date <br /> Additional Comments: <br /> r Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By oW, Date <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> f REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1•"l� <br /> LESS' <br /> PRORATION <br /> PLUS P - - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> . <br /> t <br /> Received by- Date - Receipt No. Permit No. - Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/S€RVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />