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" Applications Will Be Processed When Submitted Properly Comipteted.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> __ (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittocohstructand/orinstall thework herein described.This application is <br /> made in compliance with San Joaquin Cou y rdinanctNo. 1862 and the rules and regulations of the San o quin ca Health District. <br /> Exact Site Address 4 .� -� City/Town -� <br /> i p q <br /> Owner's Name Phone <br /> Address <br /> city, 1� N <br /> Contractor's Name License#« 2.32-3 Business Phone 1-1(1 <br /> i <br /> Contractor's Address Emergency Phoneme <br /> Is Certificate of Workman's Compensation Ins on File With SJLHD? Yes No \ <br /> TYPE OF WORK (CHECK): NEW WELL 9— DEEPEN ❑ RECONDITION❑ DESTRUCTION P, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION f PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 1O6 Pit Privy <br /> Sewage Disposal Field l Sa Cesspool/Seepage Pit Other <br /> Property r <br /> p y Line Private Domestic Well_XPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1.2— <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal Sz> (TI <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information q., <br /> El GEOPHYSICAL Surface Seal Installed By: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wall f r a Grout I pection prior grouting and a final inspe ' n. <br /> Signed X <br /> Title: Date: <br /> (Draw PI an on Reverse i e) <br /> FOR PARTMENT USE ONLY <br /> PHASE 1 Q <br /> Application Accepted By Date ? <br /> Additional Comments: <br /> Phase II Grout InspectionPhas III Final Inspection G <br /> Inspection By Date > Inspection By Date 0 <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 /> BASE EXPLANATI N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE vi <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lissuanice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />