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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F _ FICE*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 made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui C unty Or once No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name A I/ Phone �G► <br /> Address D IE doe, City <br /> Contractor's Name License#M&9 BusinessAhone -,-Z S4 yi <br /> Contractor's Address ® Emergency Ph _ ,, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No d a <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br />` WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIPJIV <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy J <br /> Sewage Disposal Field Cesspool/Seepage Pit Other +� <br /> Property Line Private Domestic Well Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> XDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: _ ,^ <br /> PUMP INSTALLATION: Contractor It I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Dona <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 orsub-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." <br /> I will call for a Grout Inspection pr'or to grouting and a final inspec' n. <br /> Signed X Title: Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date /Z.`/0 fid <br /> Additional Comments: 41 <br /> Phase Ii Grout Inspection Iff # se III Fi I Inspection <br /> Inspection By Date Inspection BDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No, Permit No. Issulance Date !Nailed Delivered <br /> APPLkCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Boji-2009 STOCKTON,CA 95201 <br />