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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) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) IIC,(k r,()ff QUALITY <br /> e nJq <br /> Application is hereby made tothnlocal ealthDistrict or rmittoconstructand/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 Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name _ Phone <br /> Address _._ �,® 2 4e City .44 nLA/7Zr — <br /> Contractor's Name- License#3AJS`S Business Phone <br /> Contractor's Address AA� Emergency Ph ne <br /> ( Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN C1RECONDITION DESTRUCTION C3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c� <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal } <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information osi <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 /> 4i <br /> i 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 j <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c r a Gro Inspe tion prior to gro ng and a final inspection <br /> Signed )( Title: _ .- <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By � Date ��J--�� 1 <br /> Additional Comments: <br /> f Phase II Grout Inspection Ph s III Final Inspection <br /> Inspection By Date Inspection 8y Date —2 <br /> r <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 J <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE tpa r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �s=3S-7 <br /> Received 4y Date Receipt No. Permit No. Issuance Date Mailed -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />