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Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign 1neAppncauun. <br /> EFOROFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> (COMPLETE 1 TRIPLICATE) WATER QUALITY <br /> Application is heTRIPLIreby detotheSanJoaquinlocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is I <br /> made in compliance with San Joaquin County Ordinance�Nc-o�. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 02C/ City/Town <br /> Owner's Name Phone Z <br /> Address _ City <br /> Contractor's Name License# /a Business Phone <br /> Contractor's Address N. <br /> 1 Emergency P one UJ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK ((jHECK): NEW WELLX DEEPEN ❑ - RECONDITION❑ DESTRUCTIONK—ffm x. <br /> WELL..CHLORINATION ❑ _..WELL.A.BANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ + <br /> REPLACEMENT❑ z .� <br /> DISTANCE TO NEAREST: Septic Tank„_ Sewer Lines Pit Privy <br /> Sewage Disposal.Field _� Cesspool/Seepage Pit_. Other <br /> f �� Public Domestic Well <br /> Property Line Private Domestic Well -= t •� .� <br /> INTENDED USE c TYPE OF WELL i + <br /> ❑ INDUSTRIAL ❑ GABLE_TOOL, f Dia. of Well Excavation r� <br /> ' Dia. of Well Casing <br /> DOMESTIC/PRIVATE i ❑ DRILLED , <br /> DOMESTIC/PUBLIG ' [IDRIVEN „ Gauge-of-Casing _ <br /> El IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> I] CATHODIC PROTECTION ROTARY Type of GroutL <br /> ❑ DISPOSAL ❑•OTHER = Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> �. . <br /> PUMP INSTALLATION:_ Contractor - <br /> Type of Pump ... f H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done-- . <br /> I PUMP REPAIR: ❑ State Work Done "� <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> _ "�`• <br /> Describe Material and Procedure <br /> Y <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 /> Home owner 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 Californiais <br /> F <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 workman's compensation+aws of California.” <br /> „r <br /> I will call for a Grout Inspection prior to grouting and a final inspection. ,, pate: C:� Z T� Jp <br /> Signed X Title ��— _ <br /> - (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date 1104M ' <br /> Application Accepted <br /> Additional Comments. <br /> Pha a Grout Inspection .� d Phas Ill final Inspection 3'�Z'� <br /> Inspection B Date _ <br /> I Inspection By - Date��� - <br /> k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> DATE DATE .REMITTED AMOUNT <br /> FEE <br /> "G O <br /> LESS <br /> PRORATION - <br /> PLUS a <br /> PENALTY <br /> OTHER Y <br /> OTHER <br /> Date Receipt No. Permit o. Issuance Date Mailed Delivered <br /> Received by . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />