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Applications Will Be Processed.When Submitted Properly Completed.Be Sure To Sign The Application. /J <br /> FOR.,=FICEIJSE: APPLICATION <br /> Cam 10 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY- t <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework 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 ocal ea th District. <br /> Exact Site Address,.S tv !I` d — 44& City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License#/��7 Business Phone 79,76 <br /> Contractor's Address4;j/ <br /> WZLI-ID? <br /> 1 . <br /> Emergency Phohe <br /> Is Certificate of Workman's Compensation Insurance on File Wit. Yes._ No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ - 'RECONDITION El DESTRUCTION❑F V) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL� <br /> REPLACEMENT❑ a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 111 <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 /> r' 0 DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> 0 IRRIGATION ❑ 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 /> Type of PumpH.P. ! <br /> PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: ® State Work Done 6 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> L s <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 /> t <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> I will call for a Grout Inspectio pri gr uti and a� al inspection. <br /> Signed X ! _. " e e: - Date: <br /> (Draw Plot P on Reverse Side) <br /> i <br /> FOR R DEPARTMENT USE ONLY . <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase li Grout Inspection Pase III Final IV pec tion <br /> Date Inspection y Date <br /> Inspection By - <br /> Fee IS Due: ❑ ANNUALLY "❑ PER UNIT. ❑ PER SITE ❑ EACH' ❑ January 1 &Recei aly a' y,-1-L-Reee y July 31 <br /> S REMIT <br /> BASE `E�CPLANATION- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> FEE <br /> LESS <br /> k PRORATION <br /> PLUS <br /> PENALTY <br /> I 4 <br /> OTHER <br /> OTHER <br /> ' Received by Date Receipt No. Permit No. I suancqk Datq Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.BOM 2009 STOCKTON,CA 95201 <br />