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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> v <br /> FOR MICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfors 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 Lcal Health District. <br /> Exact Site Address �� City/Town {1 <br /> Owner's Name � Phone f <br /> Address 1 �' -°-}+��' City <br /> Contractor's Name g License# o Business Phone <br /> Contractor's Address Address IXlEmergency Phone ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I ,i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRS <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 urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump �.c H.P./ S <br /> 6� <br /> PUMP REPLACEMENT: ❑ State Work Done I� <br /> PUMP REPAIR: State Work Done./u - <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 <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 10 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 f Grout Inspection prior to grouting and a final inspects C� r7 /(� <br /> Signed X Title: Date: / .��/ O 2, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date Z� ? <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph s 111 Final Inspection <br /> Inspection By Date Inspectien "'"J— 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> c <br /> PLUS <br /> PENALTY `` } c. <br /> OTHER 1 �+(? Z ,.-/II(,v,& <br /> OTHER Cvk dv�— I�C GiYl0[y <br /> Received 6y Datiq Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />