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f Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> y (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 Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith San Joaquin County Ordinance N . 1862 and the rules and re ui to of the San Joaquin of al Health District. <br /> Exact Site Address ra- iCc i�ty/Town � cT��V <br /> Owner's Name -OL -q2^4 ' Phone d <br /> Address City <br /> Contractor's Name License#13U I Business Phone �' <br /> Contractor's Address - Emergency Ph ne <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank [, 71 Sewer Lines Pit Privy ,(� <br /> Sewage Disposal Field lT(t Cesspool/�Seepage Pit --- Other OQ <br /> Property LineA —J Private Domestic Well � Public Domestic Well r-------- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> 1�1tr <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r4 W& <br /> �RIGATION 13 GRAVEL PACK Depth of Grout Seal ~" <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout '-- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4 U-2 At c 4— <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 <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 employhersons subject to workman's compensation laws of California." f <br /> cal fol a G t in on ting and a final inspection. <br /> Signed X Title: Data. �Gr <br /> (Draw Plot Plan on Reve Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i _ <br /> Application Accepted �By Date[ <br /> Additional Comments: <br /> Phase II Grout Inspection Ph II 1 1 Inspection <br /> Inspection By— Date Inspection Date s� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑PER SITE ❑ EACH ❑ January 1 &Received By Jan 31 ❑ July 1 &Received By July 31 <br /> REMIT <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 /> 1-3 z k,-"'g <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 />