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*.� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR 0.m-. , <br /> r,- (For Non-Transferable,Revocable, Suspendable) PUMP&WELL .� <br /> ENVIRONMENTAL HEALTH'PERMIT J <br /> (COMPLETE IN TRIPLICATE) _ WATER QUALITY <br /> Application is hereby madetothe an Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wiW San Joaquin County Ordina 1No. 1862 and the rule and r guI tions of the San Joaquin Local Health District. ' <br /> Exact Site Address � � o rC-i City/Town (c I <br /> Owner's Name Phone <br /> Address ` _ City <br /> Contractor's Name " License#L4Wz.X7 Business Phone <br /> Contractor's Address Emergency Phone ; <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPEfOF WORK (CHECK) NEW WELL DEEPEN ❑ RECONDITION O DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST:" Septic Tank { r Sewer Lines k 'Pit Privy <br /> - Sewage Disposal Feld Cesspool/Seepage Pit �---�- Others <br /> Property Line.. (_ Private Domestic Well-521) :k Public Domestic Well <br /> INTENDED USE TYPE OF WELL rl <br /> ❑ INAUSTRIALr ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> XIRRIGATIONS A GRAVEL PACK Depth of Grout Seal ) <br /> ❑ CATHODIC PROTECTION ..ROTARY Type of Grout <br /> ❑ DISPOSAL �. ❑ OTHER Other Information r— ) <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �.,_ :�.f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMEN?: ❑ State Work Done <br /> PUMP REPAIR: t ❑ State Work Done <br /> DESTRUCTION OF WELL: Well.Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 /> 4j permit is issued, I sh I em loy,persons subject to workman's compensation laws of California." <br /> KI call for Gr Ins c tfn.prior to groutfn <br /> Signed X Title: Dale: <br /> m�- (Draw Plot Plan on Rie e4 Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,� .i > <br /> Application Accepted ti Date ` <br /> Additional Comments: ` <br /> Pt �It Grout Inspection 4 P e 111�p�� <br /> Final Inspection <br /> rInspection By Date �J Inspection By Date N <br /> Fee 15-Due•-I]'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ► ~' ~ l VIA -\, " ` da "hBILLING REMITTANCE $ REMIT <br /> 4 BASE EXPLANATION' r AMDUNT DUE CHECKED <br /> BATE DATE REMITTED AMOUNT <br /> FEE. - - <br /> LESS <br /> PRORATION <br /> { <br /> PLUS <br /> PENALTY <br /> 'i OTHER <br /> i OTHER <br /> s0 <br /> . 'Received by 'Date Receipt No. - Permit No. lissuancefDate Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 1 <br />