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Applications Will Be Processed When Submitted Properly Completed. Be-.Sure'�To'Sign 1 Q pplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Siendable) PUMP&WELL <br /> ENVIRONMENTAL HE4L1'NRMITnC,� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY\ <br /> ( IV <br /> Application is hereby made to the San Joaquin Local Health District fora permit to const ut;t and/or install the+nio herein described.This application is <br /> r <br /> made in compliance with San Joaquin Coun y Ordinance No.1862 and the rules and regulatio of'theN5 n Joa u.n Local Health District, <br /> Y <br /> Exact Site AddressfC44.e n <br /> a <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# �'/ Business Phone1 <br /> Contractor's Address e 7 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L_,"' No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR[ �f`} <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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, Ae <br /> PUMP REPLACEMENT: El State Work Done . <br /> PUMP REPAIR: J9 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> 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 laws of California." <br /> I will call for a G 1 Inspection prior to grouting and a final Inspection, <br /> Signed X Title: Date: Z <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. � 'S l <br /> Application Accepted By ,11 Date +a <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspectionf <br /> Inspection By Q.6 1 Gkr,— Date Inspection By Date !2 ZZZ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ey January 31 ❑ July 1 &Received By July 31 <br /> BELLING REMITTANCE $ REMIT <br /> T <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS C]•p �v�/ I r <br /> PENALTY <br /> OTHER <br /> r U-1--• <br /> OTHER <br /> i <br /> Received by D to I Receipt No. Permit No, Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2OD9 STOCKTON,CA 95201 r <br />