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f , OT <br /> Applications Will Be Processed When Submitted Properly Completed. e u <br /> APPLICATION <br /> FOR OFFICE use: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT (/ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permi -to construct and/or install the work herein described.This application Is <br /> made in compliance withSan Joaquinpmnty Ordinance No. 1862 and th rules and regulations of the S J aqui Local Health District. <br /> 1 City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name <br /> City �- <br /> Address Business Phone <br /> Contractor's Name <br /> License# <br /> Emergency Phone � <br /> Contractor's Address No <br /> RECONDITI <br /> Is Certificate of Workman's Compensation Insurance on File With SRECO Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ ON❑ DESTRUCTION❑ <br /> PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT O OTHER 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank '7'SJ Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other I <br /> Property.Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL # <br /> ❑ INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE [3DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> t <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done y <br /> Well Diameter � Approximate Depth <br /> DESTRUCTION OF WELL: �� o _ <br /> Describe Material and Procedure pd <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 /> ILA <br /> fff 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 or sub-con signature certifies the following:"I certify that in the performance of the work for which this <br /> ct to workman's compensation laws of California." <br /> permit is issued, I shall employ persons subje <br /> I will call for a Grout In ection prior to grouting and a final inspection. <br /> Title: �' Date: <br /> Signed <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i Date`-Z,—,, <br /> Application Accepted By <br /> Additional Comments: <br /> F� Phase III Final Inspection <br /> Phase II Grout Inspection �.7 �C ..g( <br /> Inspection By <br /> Date "1 "� Inspection By � — Date <br /> ❑ ❑ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv cl By July 31 <br /> Fee IS Due: ANNUALLY PER UNIT <br /> C BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 t <br /> [ ! <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by ate 95 P <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />