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Applications Will Be Processed When Submitted Properly Completed. Be sure iosign inei+ppncaliuu <br /> FP?_OFFtIGEJUSE�--� APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San J9 n ounty Qpoinance No.1862 and th ul and regulations of the San Joaquin Local ealth J istrict. <br /> Exact Site Address <br /> City/Town <br /> Owner's Name G' 1 Phone <br /> Address City <br /> Contractor's Namef License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on F=ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION El---PUMP REPAIR❑ <br /> REPLACEMENT❑ /� 4 C <br /> DISTANCE TO NEAREST: Septic Tanis Sewer Lines / Pit Privy. ? <br /> Sewage Disposal Field �` Cesspool/Seepage Pit Other <br /> Property Line/16`t Private Domestic Well f" Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ C LE TOOL Dia. of Well Excavation— <br /> Q[ <br /> xcavation i <br /> ,l51:T 1ESTIC/PRIVATE LLED Dia. of Well Casing <br /> Q I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l <br /> ❑ IRRIGATION JD GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION WOVkRY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> © GEOPHYSICAL 1n Sur fe Seal tal(,ed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i 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 /> r Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> L <br /> 1 all for o nspection prior to grouting�Plot <br /> final inspectio <br /> k Signed X Title: Date: <br /> (Drawan on Revere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI { 1~ <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phs II Grout Inspection Ph se III Final Inspection <br /> Inspection By (� Date inspection ByDate <br /> Fee Is Dile: ❑'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I ` <br /> FEE `li , L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f OTHER <br /> F OTHER <br /> r Received by Date ,.Receipt No. Permit No. 1 uan Date Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTR PERMIT/SERVICES 1601 E:14AZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />