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Applications Will Be Processed When Submitted Properly Completed:Be Sere To Sign.The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT " /3 " <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY <br /> Application is hereby a San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wwgEmcioaquin ly Ordinance No. 1862 and the rules and regulations of the Sa oaquin Local Health District. <br /> Exact Site Address P Cit /Town ,.,. <br /> Owner's Name Phone s <br /> 7-7 <br /> Addressr� City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address got efl.1-- Emergency Phone <br /> 1s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION© PUMP REPAIR- <br /> REPLACEMENT 13 <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 /> ❑ IN <br /> PLISTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 12'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ; <br /> CATHODIC'PROTECTION ❑ ROTARY 'Type of Grout , <br /> C <br /> ❑ DISPOSAL ❑ OTHER Otheranforniation ` <br /> ❑ GEOPHYSICAL Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pume-� H.P. ��, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> DescribeMaterial and-Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with_San Joaquin CoufS#p., <br /> ordinances,state laws,and rules and regulati®ns of the San Joaquin LocaE.Heatth District. " <br /> Home owner or licensed agent's signature certifies the following;"I certify,that in the performance of;he work for whichthis permit _ <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Callfornla;' , <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 /> f wuitlo fka tion prior o.grouting and a final inspection ..,. <br /> Signed Title: <br /> (Draw Plot Pian on Reverse Side)' <br /> F DEPARTMENT-USE ONLY` ; <br /> PHASE I ' <br /> Application Accepted By Dale /)` <br /> Additional Comments: - <br /> Phase II Grout Inspection se final Ins ion `- <br /> Inspection By Date inspection By Inspection <br /> �F <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> '" ' <br /> BASE ' ' EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE }ATI REMITTED AMOUNT-- <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 Co <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Sox 2441 STOCKTON,CA 95201 <br />