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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -FORO4`11'C-E HSE: APPLICATION <br /> e-m PAP/M0111 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqui n Local Health District for a permit to construct and/or install the work herein described.This application is <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 __ _ __ City/Town <br /> Owner's Name I'I .r Phone <br /> Address G 3 O '✓ 1=2 / City <br /> - <br /> Contractor's Name License# /fa �J Buslness Phone_ VA 't 4 <br /> Contractor's Address ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ECONDITION❑ DESTRUCTION❑ } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 0i <br /> REPLACEMENT❑ I <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 /> 19 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 LOY <br /> ❑ GEOPHYSICAL Surface Seal Instal y: 11 <br /> A <br /> PUMP INSTALLATION: Contractor 4 0, w <br /> SA <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 19 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 subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection r u"ngL d a final inspection. <br /> SignedFZ1' Date: <br /> (Draw Plot PI on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I /Llla <br /> Application Accepted By �/ — <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection has 111, 1 'al Inspecti <br /> Inspection By Date Inspection By� i (, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 2f PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE K v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> Received by Date Receipt No. Permit No. Is ance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />