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_Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ARrICE'usE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE). Oid 3 5 WATER QUALITY f 93— <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 wh San Joa in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name w' Phone_9 3 / ­­ / 7 S <br /> Address L City QN3— <br /> Contractor's Name I V License# Business Phone <br /> Contractor's Address3 6A. o Emergency Phone �� <br /> Is Certificate of Workman's Compensation Insuranc on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION & -� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank d Sewer Lines ")V- , Pit Privy C� ` <br /> Sewage Dispos I Field w, w-t Cesspool/Seepage Pit 41 Other f V <br /> Property Line�rivate Domestic Well "tA Public Domestic Weli <br /> INTENDED USE TYPE OF WELL O <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation V" <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing fig <br /> �❑ D.OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 91 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: ContractorCI <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> 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 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 X Title: roAer ga,4 _. Date: r <br /> (Draw Plot Plan on Reverse Side) / <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase Ii Grout In Ilion Phase III Final Inspection <br /> Inspection By Date Inspection By r . __ - Date j- <br /> Fee IS Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ' LJ July 1 &Received By July31 <br /> REMIT <br /> BILLING REMITTANCE $ <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 /> �9 ► � � f� � <br /> Received by Date Receipt No. Permit No. llssuabce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952DI <br />