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Applications Will B#Prot4,*,sed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: 1 APPLICATION <br /> & (For Non-Transferable,Revocable,Suspendable) <br /> ! PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> S <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address , A pA@L Tre of City/Town <br /> Owner's Name 14 d 1CA% bt I&L Phone <br /> Address City <br /> Contractor's Name License#/ + 7Y Business Phone__ '7,L ?"d <br /> Contractor's Address V0Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? 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 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal I stalled By: <br /> PUMP INSTALLATION: Contractor C>,>t <br /> Type of Pump H.P. ��s•'' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP*Vrow. Od 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 /> 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 for which this <br /> permit is issued, I shall employ persons sttb1MWto workman's compensation laws of California." <br /> Iw' call fo a Grout Inspec ' riA to gro =al al inspection. <br /> Signed r> itle: &� Date: <br /> (Draw Plo an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> Application Accepted By- °" Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection h se II Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT i <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> 4-5 AMOUNT <br /> FEE L CC L� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —7 9`I 6--.— <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 AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />