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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign TheApplication <br /> FOR OFFICE USE: APPLICATION <br /> L / (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ATER QUALITY <br /> (COMPLE=TE IN TRIPLICATE)_-"(It W . 1Et_'77 C-10— ��!' C <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install theworkherein described.This appli tion is <br /> made in compliance with San Joaquin Count rdinan a No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Mc r o City/Town <br /> Owner's Name Phone <br /> _ City '+ <br /> Address � O I <br /> Contractor's Name 157 >J "' License# Business Phone <br /> Contractor's Address R de 10 <br /> �Wit <br /> Emergency PhoneIs Certificate of Workman's Compensation Insurance oD? Yes�— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 ❑ CABLE TOOL pia. 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 PROTEC71ON ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ..+ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump k H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ✓ <br /> PUMP REPAIR: N 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 tri 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 /> Ps 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 /> I ill call for a Grout lnspecticl riorto g . ting an a final inspection. <br /> Signed Title: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Ir'G Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout InspectionPha a III Final I��ns,pe��cti n <br /> Inspection By Date Inspection By D , 'a <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 /> ov �Y <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT1sERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />