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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FO It OFFICE USE: APPLICATIO <br /> y may, (For Non-Transferable, RevocablSuspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> TRIPLICATE) WATER QUALITY <br /> (COMPLETE IN TRIP <br /> Application is hereby ICAT the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> lth <br /> made in compliance with San Joaquin County OrdinancgJ)o. 1862 and the Frules and rpegul Ins of tthhe Sap�JJpaquin Local HeaDistrict. <br /> / ,�- "f-•4',:•� i..ry c?7` � dWn <br /> Exact Site Addres6� it r <br /> Owner's Name Phone <br /> ', .'"j � �;� ,� � City <br /> 7r S � <br /> Address <br /> � „ -�- ., ��� License#. '��% fir` Business Phone <br /> Contractor's Name <br /> Contractor's Address x ` r " Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLIS1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ / . <br /> DISTANCE TO NEAREST: Septic Tank 1 Sewer Lines Pit Privy "'"" <br /> d " <br /> Sewage Disposal Field _ Cesspool/Seepage Pit Other <br /> Property Line - - Private Domestic Well: Public Domestic Well <br /> INTENDED USE TYPE OF WELL cf <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation r� <br /> 11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ��: ------ <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> n <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 /> 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." vl <br /> 1 will-ca-0 for a Grout Inspectign pFYor to grouting and a final inspection. <br /> c <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse,Side) <br /> ,. FOR FbEPARTMENT USE ONLY <br /> PHASE I ' <br /> Date,, <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I suanceDate Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No <br /> 7601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ` <br />