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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFF.JCE USE: APPLICATION <br /> (For Non-Transterable, Revocable, Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ( , <br /> 5 WATER QUALITY <br /> COMP ETE IN TRIPLICATE) ,�of t <br /> Application is hereby madetothe San Joaquin Local H9alth District far 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 Joaqui cal Heal h District. <br /> Exact Site Address y City/Town <br /> J Phone.@ �" b <br /> Owner's Name _ Y 1�- - <br /> • City�a—���� <br /> Address <br /> Contractor's Name r e License#�2Business Phone <br /> Emergency Phone <br /> Contractor's Address _ j <br /> Is Certificate of Workman's Co pensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ __S) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 4K 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 /> ❑ 1 'rte ❑ CABLE TOOL Dia. of Well Excavation <br /> LIY'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC ❑ 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 /> 11 GEOPHYSICAL o Surface Seal I stalled By,% <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <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 /> Horne owner or licensed agent's signature certifies the following:':I certify that in the performance of the work for which this permit <br /> E 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this -� <br /> permit is issued, I shall ploy perso nssubject,yo workman's compensation laws of California." <br /> 4W I <br /> I will all for a Grout Inspec ion prior o grouting and a final inspection. <br /> Signed '- Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Q <br /> Application Accepted By Date `s z <br /> Additional Comments: - <br /> Phase II Gr Inspection hese final inspection <br /> Inspection fay <br /> Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER'UN4T ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1'&ReceiveRd By Ju$y 31 <br /> EMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> t S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER + <br /> OTHER `� k <br /> Received y ate Receipt No,'-- = Permit No, - Issuance Date s Mailed -Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMMSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />