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pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Y <br /> FOR-OFFffCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ----- ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,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 Joaqui Co y Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Z City/Town <br /> Owner's.Name. �. <br /> Address © Phone <br /> City <br /> Contractor's Name License Business Phone' <br /> Contractor's Address 'Emergency Phone ���� •- <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes 1✓ No <br /> TYPE OF WORK (CHECK): '_ NEW WELL❑' DEEPEN ❑ RECONDITION❑ ...DESTRUCTION❑ (� <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ©' PUMP REPAIR <br /> REPLACEMENT❑ g / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines / d Pit Privy 'r ! <br /> Sewage Disposal Field <br /> 2,611-1 Cesspool/Seepage Pit — Other <br /> Property Line Private Domestic Well r Public Domestic Well <br /> INTENDED USE TYPE OF WELL r. <br /> ❑ iN17C7S RIAL ❑ CABLE TOOL � 'Dia: of Well Exca ation .b <br /> OMESTIC/ TE + ❑ DRILLED Dia. of Well Casing _ fo 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK { Depth of'Grout Seal' <br /> ❑ CATHODIC PROTECTION 19-VOTARY `' <br /> ,Type of Grout <br /> ❑ DISPOSAL ❑ OTHER- Other-Information <br /> El GEOPHYSICAL Surface Seal Installed By: j, <br /> PUMP INSTALLATION. Contractor f�`J <br /> � a <br /> Type of Pump— ey-- 161 10 <br /> --�. _ H.P.,� <br /> PUMP REPLACEMENT: ❑ 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 hereby certify that I'havie prepared this-application and that tfi6_work will Ue 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:1 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 /> F <br /> I trR901 call or a Grau pspection prior to grouting and a final inspection.. ' <br /> Signed X - �^� Title: I�/��'l� Date: <br /> ?' (Draw Plot an on Reverse de) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE , <br /> Application Accepted By - Date <br /> Additional Comments: i <br /> e.11 Grout Inspection NI <br /> j� h �1;1 �Inspe�clio�,�&�Inspection B Date 4R r .� Inspection B <br /> Fee is Due: ❑ ANNUALLY -'t❑ PER UNIT ' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31" ❑ July 1 &Received By July 31 <br /> t BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> .1� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ¢ - <br /> OTHER <br /> Received by - Date Receipt No. -Permit No. I Issu nce Date- Mailed DBlivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> a+ r <br />