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ApplicationsWill Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> 4 FOR OFFICE USS t APPLICATION <br /> f (For Non-Transferable, Revocable,Suspendable) <br /> i ENVIRONMENTAL. HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY J-4T - t <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui Count Ordi ce No. 1862 ante rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ����. Y, e � �� r <br /> }g R-' d _ City/Town <br /> Owner's Name �' {.N -- PhoneZ <br /> Address - City <br /> Contractor's Name I License# � �' <br /> ��rBusiness Phone <br /> Contractor's Address -P.O �s� Emergency Phone __-S <br /> al'r Is Certificate of Workman's Compensation Insurance on File 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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> MESTIC/PRIVATE ❑ DRILLED 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 /> NI <br /> ❑ GEOPHYSICAL I c Surface Seal Installed By: { <br /> PUMP INSTALLATION: Contractor_ <br /> Type of Pumpr H.P. 6 <br /> PUMP REPLACEMENT, 0 State Work Done <br /> PUMP REPAIR: ❑ State Work Done .1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t <br /> Describe Material and Procedure I <br /> 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. j <br /> Homeowner 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-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 will for a GrouI In pection prior to grouting and a final inspection. <br /> Signe J .�__. Title: vv- ..- Date: 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE 7 <br /> Application Accepted Fay Date ( � <br /> Additional Comments: <br /> Phase II Grout Inspection phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS DUE: El ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ¢ �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. .Permit No. Issuance Date Mailed Deliv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 .STOCKTON,CA 95201 <br />