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it Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OR'OFFICE USE: r APPLICATION - <br /> .� (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan Joaquiri Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin puntrdi ce No. 1862 an the rules d r ulations of the San Joa Local Health District. <br /> Exact Site Address 121V City/Town <br /> Owner's Na Phone <br /> Address City l!✓ af? d <br /> Contractor's N icense# Business Phone d <br /> Contractor's Address - 1{ Emergency Phone !V 3q y <br /> rTjT.- <br /> Is Certificate of Workman's C pensation irisurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLZ-�DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -� <br /> WELL CHLORINATION ❑, WELL ABANDONMENT ❑ OTHER"D PUMP INSTALLATION 9—PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Ila Sewer Lines Q / Pit Privy <br /> Sewage Disposal Field/ Cesspool/seepage Pit - Other <br /> Property Lined Private Domestic Well 47�-e_ Public Domestic Well � -4�- <br /> INTENDED USE TYPE OF WELL �� { <br /> ❑ <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 ❑ GRAVELPACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 2 F -0TARY Type of Grout A, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP iNSTALLATION: Contractor , I - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not employ as ny,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 /> ermit is issued, I sha arsons subject to workman's compensation laws of California." , <br /> I I call fora t I pe on rior o grouting and a sinal inspection. <br /> Sign Tltle: Date: <br /> NJ (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 1 <br /> P _ - 1 <br /> Application Accepted By IL Date <br /> Additional Comments: - i <br /> Ph a II out Inspection Q Ph e 1 final Inspection _ <br /> Inspection By Date I f v- Inspection By Date <br /> Fee is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 El July 1 &Received 8y July 31 <br /> ' REMIT rS <br /> BASE ExPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE GATE REMITTED AMOUNT <br /> FEE f # . 't <br /> LESS + <br /> PRORATION ..•..;, - ' <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Ly I Ivor <br /> Received byDate 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 />