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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ' ENVI NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER_QUALITY <br /> Application is hereby made to the San Joaquin Local HealthDistr' fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with an Joaquin County Ordi ce No. 1862 and the rule��and r gulations of the San a uin Local Health District. <br /> Exact Site Address Q �'} ��City/Town q <br /> Owners Name {' .. J 4. 3 k <br /> Phone <br /> Address 4 � City <br /> Contractor's Name i' License# I Business Phone <br /> Contractor's Address Emergency Phone } <br /> Is Certificate of Workman's Compensation I urance on'File With SJLHD?_ Yes X No f! <br /> TYPE OF WORE( (CHECK): NEW WELL DEEPEN ❑ - 'RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11T <br /> r REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic tank-:" Sewer Lines <br /> ' Pit Privy <br /> Sewage Disposal Field r- Cesspool/Seepage Pit Other <br /> Property Line --� Private Domestic Well 3Q Public Domestic Well <br /> INTENDED USE TYPE OF WELL �1 ; <br /> ❑ INDUSTRIAL a 0 CABLE TOOL Dia, of Well Excavation <br /> . XDOMESTIC/PRIVATE ❑ DRILLED _ Dia. of Well Casing- l <br /> ❑ DOMESTIC/PUBLIC ',❑ DRIVEN Gauge of Casing fI t <br /> ❑ IRRIGATION .GRAVEL PACK Depth of Grout Seal 1 <br /> l ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL u OTHER Other Infor <br /> ❑ GEOPHYSICAL ►f Information <br /> Surface Seal Installed By:. t <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: El 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 wgrk'forwhich 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." 7 <br /> Contractor's hiring or sub-contracting signature certifies the following: 4 <br /> "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 for a Grout I p tion prior to grouting and a final inspection. { <br /> Signed X r <br /> Title: Date: <br /> s <br /> Draw Plot Plan on Reverse Side) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By_ Date �� <br /> Additional Comments: O j <br /> Kase It Gr t Inspection �� �. r Phase III F pal Inspect on <br /> Inspection By Date Inspection By ${AA � Date <br /> Fee Is Due: ❑ ANNUALLY []:PER UNIT ❑ PER SITE <br /> EACH ❑ January 1 8 Received By January 31 ] July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE - $ e 1" 1 3 REMIT <br /> DATE DATE REMITTED AMOUNT DUECHECKED <br /> ` AMOUNT i <br /> FEE (f 7> .4r. <br /> LESS X17 * � '� A <br /> PRORATION <br /> PLUS <br />'"•' PENALTY �•ti' ' <br /> OTHER <br /> OTHER <br /> Received by Dater - = Receipt No i~ - --..—. Permit No s "Issuance Date. Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered <br /> - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 s <br />