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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 g+WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE-I TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Hoa lthDistrict for apermit toconstruct and/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 aQ City/Town <br /> Owner's Name Phone .24 <br /> K <br /> Address City �x r <br /> License# . /� Business Phone <br /> Contractor's Name <br /> Contractor's Address r7 `� r` Emergency P one <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):' NEW WELLX-:1 DEEPEN ❑ RECONDITION❑ -DESTRUCTIONS U� <br /> WELL.CHLORINATION ❑ ,w,..WELL.A:BANDONMENT ❑ OTHER ❑. PUMP INSTALLATION ❑ PUMP REPAIR _ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: SepticTank �.r.._ Sewer Lines Pit Privy w <br /> Sewage Disposal Field Cesspool/Seepage,Fit, Other <br /> Property,Line Private Domestic Well Public Domestic Well•- <br /> INTENDED USE ,` a TYPE OF WELL <br /> ❑ INDUSTRIAL13 CABLE-TOOL; Dia. of Well Excavation i I <br /> DOMESTIC/PRIVATE _ r ❑ DRILLED. Dia. of Well Casing <br /> " " ❑ DRIVEN .: Gau a of`Casin <br /> DOMESTIC/PUBLIC 9 9 <br /> ❑ IRRIGATION : ��a GRAVEL PACK Depth of Grout Seal l <br /> ❑ CATHODIC PROTECTION ROTARY * t Type of Grout - <br /> ❑ DISPOSAL 13-OTHER - Other Information l <br /> ❑ GEOPHYSICAL _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <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 CT)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 /> Home owner or licensed agent's signature certifies the following:''J 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." 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this f <br /> permit is issued,-I shall-errlplb5 persons-subject to workman's compensation laws of California." �3 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. , <br /> Signed <br /> Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) ;, I <br /> FOR DEPARTMENT USE ONLY F <br /> PHASEI <br /> j Application Accepted Date <br /> Additional Comments tZ-�``• '�' - <br /> Pha a Grout Inspection - r _ Ph s 111 Final Inspection _ <br /> Inspection By Date <br /> Inspection B Date . . <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r REMIT <br /> FBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE ExPLANATION DATE DATE .REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ` <br /> PRORATION J <br /> PLUS <br /> PENALTY.. a <br /> OTHER .. <br /> OTHER <br /> i <br /> D7�3 <br /> I Received by -.-Date Receipt NoPermit r4o. s -Issuance Date „ Mailed _ Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/4RVICES-, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />