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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> FOR OFF 0E USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL { <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY x <br /> Application ishere e�e oaq o al ealthDistrictforapermittoconstructand/or instailthe wok herein described-This application is <br /> m e c i n o um Co r finance and the rul and regu ations of the San Jaquin Local Health District. <br /> E> ct it+ dress City/Town <br /> Alm <br /> Owner's Nie _ Phone <br /> Address + City l y <br /> Contractor's Name k -License#, Zino. <br /> ; usiness Phone" f •" <br /> Contractor's Address ' '- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK•(CHECK):' NEW WELL❑- I3EEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ - PUMP INSTALLATION ❑ PUMP REPA <br /> IAe <br /> ❑� <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 r ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ; <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information p , <br /> ❑ GEOPHYSICAL - Surface Seal Installed.By: N <br /> PUMP INSTALLATION: Contractor a <br /> L <br /> Type of Pump H P 1/\ <br /> PUMP REPLACEMENT: - ❑ State Work Done ,� v <br /> PUMP REPAIR: State Work Done . y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 California." <br /> ,i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance Of thework forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout Inspection prior to grouting and a final insp on.-+ <br /> Signed X - Title: . _._ Date: <br /> (Draw Plot Plan on Reverse Side) € <br /> rt OR DEPARTMENT USE ONLY <br /> PHASE I <br /> -Application Accepted By < -- Date�a <br /> Additional Comments f _ <br /> Phase If Grout Inspection ha III at Inspection / <br /> Inspection By r __ {.•Date = Inspection By ;V_4 <br /> Date <br /> {{t <br /> Fee`Is Dile: © ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH r ❑ January'1 &Received By JanuaFy 31 ❑ July I &Received By July 31 �P <br /> t REMIT <br /> BASE' EXPLANATION BILLING' REMITTANCE $- r <br /> DATE DATE !REMITTED AMOUNT DUE CHECKED <br /> #' � AMOUNT � <br /> FEE <br /> LESS • - a <br /> PRORATION <br /> PLUS <br /> PENALTY, <br /> .OTHER <br /> OTHER <br /> Received by Date -- } Receipt No.! Permit No. - Issuance Date Mailed - Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />