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t ti"Applications Will Be Processed When Submitted Properly Completed. oe sure Iosign Ine Kpprr�auvn. <br /> FOR OFFICE USE: APPLICATION ' <br /> (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL <br /> I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance�h�Saann Joaquin unty Ordin ce No. 18P2 and the rules and regulations of the San Joaquin Local Health District. <br /> i Exact Site Address � City/Town <br /> Owner's Name Phone <br /> Address ,,y,�}}�������� City <br /> i Contractor's Name ^� License#3v9Y Business Phone <br /> Contractor's Address 3Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No — <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W <br /> F WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP 1NSTALLATIONO PUMP REPAIR❑ <br /> e <br /> REPLACEMENT❑ l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit �Z.�i/.n�� _ Other <br /> Property Line YO /Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ! r <br /> 13 INDUSTRIAL ABLE TOOL Dia. of Well Excavation <br /> t' DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> c 1:1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout u <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 12 GEOPHYSICAL Surface Seal Installed By: . <br /> PUMP INSTALLATION: Contractor <br /> t• Type of Pump 34,76, H.P. <br /> ! El State Work Done <br /> PUMP REPLACEMENT: d <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 thework for which this permit <br /> i. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f ollowing:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the f <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> r 1 will II for a Grout Inspection prior longrouting and a final inspection. <br /> Date: <br /> A` <br /> Signed X Title: 0 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments <br /> �Pe rout Inspection P e Ill Final Inspection oInspection By '� Date 6 Inspection By Date <br /> fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary 1 &Received By January 31 ❑ Juty 1 &Received REMITuIy 31 <br /> By <br /> .. <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> _ DATE DATE REMITTED AMOUNT <br /> FEE <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER IN <br /> OTHER <br /> IsT - <br /> Received by <br /> Date Receipt No. Permit No. Issua ce Date Mailed Delivered - <br /> 1601 E.HAZELTON RYE.,P.O.Bax 20x9STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERYICES <br />