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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EFOFFICE usE: / APPLICATION <br /> &htp<6 (For Non-Transferable, Revocable, Suspendable) J <br /> ENVIRONMENTAL HEALTH PERMIT r PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ounty rd ina ce No. 1862 and the rules and regulations of the San Joaq I o i Health District. <br /> Exact Site Address 0Q City/Town <br /> Owner's Name " ,� .fel n"V!;,ro Phone <br /> Address <br /> Contractor's Nam Gity stF <br /> a License# "���� Business Phone C)- 7 4C <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? 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 r f <br /> INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVENI <br /> Gauge of Casing JI <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By; <br /> PUMP INSTALLATION: Contractor <br /> a r,` <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: .P State Work Done j <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 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 orsub-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 w l call for a Grout Inspect' n ri r t grou ' g and nal inspection. <br /> Signed X Itle: Date: <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection I <br /> Phase III Final Inspection <br /> Inspection By 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 /> BASE EXPLANATION BILLING REMITTANCE $ FA"MOUNT <br /> REMIT <br /> DATE DATE REMITTED CHECKED <br /> AMOUNTFEELESSPRORATIONPLUS <br /> PENALTY ,. <br /> OTHER <br /> OTHER <br /> G11clit > <br /> Received by Date Receipt No, ermit No. issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20{19 STOCKTON.CA 95201 <br />