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Applications Will Be Processed When Submitted Properly CompletedFBe Sure To Sign TheApplication. <br /> FOR OFFICE USE: I APPLICATION <br /> �5 M /w i�� (For Non-Transferable, Revocable, Suspendable) -= I <br /> 1_ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 6 - WATER QUALITY / �7 3— 2-,(e0-0_3 <br /> (COMPLETE IN TRIPLICATEpz'(f--UT-, g�t�ry?4,-�v <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework 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 Healt District, <br /> Exact Site Address �n a y prr�l o f ea a r & I�ty/Town - 1 <br /> if <br /> Phone <br /> Owner's Name IX <br /> 5'111111 <br /> Address City a <br /> Contractor's Name License# Business Phone <br /> Contractor's Address _ Emergency Phone rn{ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION ❑ PUMP REPAIR® 1 <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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r t <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing — <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Vy IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION C] ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal LII By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 19 State Work Done r6� <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 1 <br />� ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit - <br /> is issued, 1 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 <br /> permit is issued, I shall employ persons subject to, rkman's compensation laws of California." <br /> I w' call for a Grout InspectlQJLp o to r ng a al ins peciiory^) f <br /> Dale: ^ . <br /> Signed " { <br /> (Draw Plot PI n on Reverse Side) <br /> j <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE 1 Q <br /> Application Accepted By� X11 �� A Cf O Date u <br /> Additional Comments: <br /> Phase II Grout Inspection / P III Final 4lspectiong 6_p <br /> Inspection By Date r Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &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 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Iss ante D to Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />