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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> =RIPLICATE) <br /> APPLICATION <br /> (For Non-Transferable, Revdcable,`Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made,in compliance with San Joaquin County Ordinance No. 1882 and he rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phonem- .ela—a'3VI <br /> Owner's Name S City - � - <br /> Addressrye F�� -��J <br /> Contractor's Name 7 License#42 f� Business Phone 1' --- <br /> , <br /> Contractor's Address a ' <br /> 1,41 Emergency Phone " <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes.�✓ _ _ <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privyti <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 _ 11!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. <br /> C' <br /> PUMP REPLACEMENT: State Work Done d <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k <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 pp.� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. CA <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wi II for a Grout 1 ciion riot to grouting and a final inspec' + 41 <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q Date ` <br /> Application Accepted By <br /> Additional Comments: ; <br /> Phase II Grout inspection ys Final Inspection <br /> Inspection By �� Date Inspection B Date '� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑'PER SITE © EACH ❑ January 1 &Received By January 31 July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> ate - Receipt No. - Permit No. - Issuance Date Mailed Delivered <br /> Received by -- <br /> . 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCNTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />