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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> ' APPLICATION <br /> �. (For Non-Translerable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I1 (j <br /> (COMPLETE IN TRIPLICATEN " + i WATER QUALITY <br /> Applicationisherebymade tothe 3anJoaqui ocalHealthDistrictforapermittoconstructand/orinstallthework herein described.This application is <br /> made in compliance with San oaquin Cc Ordinance No. 1862 and he rules and r ul�tions of the San Joa 'n Low Health District. <br /> Exact Site Address !N J � City/Town <br /> Phone <br /> Owner's Name ) <br /> Address 2 - S , City <br /> Contractor's Name �12License# Business Phone <br /> Contractor's Address �/v 1. Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ~�y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 j! <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <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 - 01 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ? <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. j /L� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br />_ DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> certify that 1 have prepared this application and that the work will be,done in accordance with San Joaquin County <br /> I hereby y P P <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." 1 <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 win;7=7;7zan <br /> final inspection. CT7Date•Signed XTitle:Plan on Reverse Side) <br /> 4 <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I 3 <br /> Application Accepted By Date T <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection I <br /> Inspection By Date Inspection By Date <br /> L1L1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> pA� DATE DATE REMITTED AMOUNT <br /> FEE 7© -s S -� <br /> LESS 1�� <br /> PRORATION ' <br /> PLUS j <br /> PENALTY <br /> OTHER <br /> OTHER _,3 mwq �,s <br /> 7 <br /> Received by I Date -r Receipt No. Permit No. Is ante Dole Mai$ed Deiivered �'�� <br /> L APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009: STOCKTON{cy4y3eu9 i <br />�. r` fLIC+�// <br />