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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR Ii UP : f APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is # <br /> made in compliance with San Joaquin County PLrdinai No. 1 2 and the rules and regulations of the San Joaqu LgraHealth District. <br /> Exact Site Address *� �- D City/Town " <br /> Owner's Name A&v <br /> /"Lr C e Phone <br /> Address City-Ai V <br /> Contractor's Name Sense# ��WSBusiness Phone / - <br /> Contractor's Address Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With Si, HD? Yes No x <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLOAINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 11 <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 Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Install By: <br /> PUMP INSTALLATION: Contractor <br /> I 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 1 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 toAGoorkman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify thaVin the performance of the work for which this <br /> fpermit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> l 1 H call for a Grout Ins ecli io tog Ing an a final inspection. <br /> Signe d Title: Dale: G' d <br /> (Draw Pic, <br /> P an on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I ��``__, <br /> Application Accepted By Date <br /> Additional Comments: <br /> I Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By o Date Inspection By Date <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 REMITTA $ AMOUNT DUE CHECKED <br /> DATE DA REMITTED AMOUNT <br /> d C> <br /> FEE <br /> i <br /> LESS <br /> PRORATIONPLUS <br /> / I <br /> PENALTY 'L b l we t4-,#1 <br /> OTHER .Gw/ w { !/U�-3 ! re. 11e� � �ua�y � <br /> OTHER <br /> n� <br /> Received by Date Receipt No. Permit No Is uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />