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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicali <br /> 1` FOR OFPSCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE/(11� WATER QUALITY <br /> Application is hereby madetotheS nJoaquinLocalHealthDistrictforapermittoconstructand/or install thework herein described.This application is <br /> made in compliance with San oa uin County Ordin nce No.1862 and the rules and regulations of the San Joaquin Local Health DiD'I�t. <br /> t}pact Site Address !- a City/Town <br /> Owner's Nam Phone <br /> Address yy City !2 <br /> Contractor's Name License 67-�� Business Phone —7 <br /> Contractor's Address ` Emergency Phone !P <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �" No _ <br /> TYPE OF WORK (CHECK): NEW WELL 03'-'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION®- `PUMP REPAIR❑ <br /> REPLACEMENT❑ ! / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 4 Pit Privy <br /> Sewage Disposal Field pG Cesspool/Seepage Pit Other <br /> Property Lineo�.00 0 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ iN_Q1 TRIAL ❑ CABLE TOOL Dia. of Well Excavation t <br /> E5 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing p <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea d <br /> ❑ CATHODIC PROTECTION NOTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed Ba: �n <br /> PUMP INSTALLATION: Contractor <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 /> 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 /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> I will c or Grout Inspection prior to grou and a final inspection. <br /> Signed X /` Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE II �,.����g j <br /> Application Accepted By Dated <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> �--- <br /> Inspection ByDate inspection By Date�E <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 /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A? �L_c� y>I <br /> Received by If Date Receipt No. Permit No. Issuan 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 />