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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT f <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY F <br /> ApplicatianisherebyrnadetotheSanJoaquinLocalHealthDistrictiorapermittoconstructand/or install thework herein described.This application is l <br /> •made in compliance with an.Joaquin Coun� Ordinance No. 18 2 arid the rules and regulations of the San Joaquin Local Health District. <br /> ExactiSite.Address <br /> �- B. 1,Et ;Lao City/Town <br /> Owner'"s Nam <br /> Phone <br /> City <br /> Address <br /> a< License#33 $usihess Phon <br /> Contractor's Namee <br /> Contractor's Address v� s> 'f, "'Emergency!Phone "` ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> _ n . <br /> TYPE OF WORK (CHECK): - NEW WELL"❑ "DEEPEN ❑ v "RECOND1TION❑ DESTRUCTIO,N,❑� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER.❑ PUMP INSTALLATION uJ^� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy J <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic,Well V� <br /> INTENDED USE TYPE OF WELL- r <br /> ❑ INPMSTRIAL ❑ CABLE TOOL .. Dia. of Well Excavation <br /> IOMESTIC/PRIVATE - 13 DRILLED Dia. of Well Casingl,r° <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> j ❑ IRRIGATION 11 GRAVEL PACK. Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> a <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor --: <br /> Type of Pump H.P. yi <br /> t PUMP REPLACEMENT:: 0 State Work Done <br /> r ❑ State Work Done <br /> PUMP REPAIR: , <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 /> 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 for which this <br /> permit is issued,`I shall employ persons subject to workman's compensation laws of California." C <br /> 1 will ca f a Grout Inspection prior to grouting and-a final;inspection. - <br /> Datei r <br /> Signed- - Title: , <br /> 1 (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> Application Accepted By { Date <br /> Additional Comments: <br /> Phase II Grout Inspection phase t Final Inspection r/ <br /> Inspection By Date — inspection By Date <br /> y • <br /> Fee Is Due: ❑ ANNUALLY "❑ PER UNIT -❑ PER-SITE ❑ EACH`' °❑ January 1-&Received By January 31 ❑ Juky 1 &Received By July 31 <br /> 'REMIT <br /> - � BASE� - -'EXPLANATION` ---.FBILLING REMITTANCE ,. $ AMOUNT DUE - CHECKED * - - <br /> -.....y.. '. <br /> r � DATE DATE- REMITTED- AMOUNT <br /> .... <br /> :FEE- S' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> iu } <br /> OTHER , <br /> t OTHER = <br /> Received by - Date -- r Receipt No. Permit No. _ -issuance Date Delivered <br /> .Mailed - .-- <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br />