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Applications Will Be Processed When Submitted Properly Completed. Be SureTo519n 1neApplication. <br />' FOR OFFICE USE:. • APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> yy a j WATER QUALITY a <br /> (COMPLETE I TRIPLICATE) �j `` 4 ®l/ ��"t t <br /> Application is hereby made totheSanJbaqulnLdcalHealthDistrict o itti rucland/orinstallthework 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 E <br /> Gs! J .e' City/Town e` e <br /> � � <br /> Phone <br /> Owner's Name <br /> t <br /> Address Ciy <br /> Contractor's Name a' License# Business Phone <br /> Emergency Phone <br /> Contractor's Address h✓ �y, <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes 4-1- No q <br /> TYPE OF WORK (CHECK):, NEW WELL F-1 DEEPEN ❑ RECONDITION 13 DESTRUCTION[] <br /> c WELL CHLORINATION 11 WELL ABANDONMENT El OTHER C] PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT . <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> f <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> e ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r ❑ GRAVEL PACK Depth of Grout Seal <br /> • IRRIGATION <br /> k ❑ 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 <br /> i PUMP REPLACEMENT: 0 State Work Done <br /> } PUMP REPAIR: ❑ State Work Done <br /> ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F•r - Describe Material and Procedure <br /> }f 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 li <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspe 'on prior to grouting�Plot <br /> final inspec r <br /> Signed X <br /> Title: Date: <br /> (Draw an on Reverse Side) <br /> FOR PART NT USE ONLY <br /> P PHASE 1 2 Date. '�, �� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph se III Finale Insection <br /> ✓ <br /> t inspection By <br /> Date Inspection By ate <br /> .fes <br /> r <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January t Received By January 31 Q July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DA E DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER + <br /> „ OTHER <br /> • J ..� / �V <br /> � s � Issuance Date. Mailed• � Delivered <br /> :e4ved by- Date- Receipt No- Permi[No. <br /> �PLICANT-RETURN ALL COPIES TO::�ENVIRONMENTAL HEALTH PERMITlSERYICES _ _1607 E.HAZELTON AYE.,P.O.O.B�9 -STOCKTON,CA 45201 <br />