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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I <br /> '-FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work V herein described.This application_ is <br /> made in compliance with SJoaquin Countrdinance No.1862,end,the rules and regulations of the San Joaquin Local Heaith District., <br /> Exact Site Address g ty�--�"' City/Town <br /> Owner's Name i .A Phone <br /> Address ,5;, ¢ Caen T' cityOF <br /> �� <br /> Contractor's Name License Business Phone ��+ 1 <br /> Contractor's Address Emergency Phone <br /> 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 1:1 OTHER El PUMP INSTALLATION MP 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 /> ❑ INP�WSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L4,i6bMESTIC/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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P, - - -_ r►a <br /> PUMP REPLACEMENT: ❑ State Work Done 67 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure V' <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'slgnature 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 /> Contractors 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 /> C If Grout Inspection prior to grouting and a final inspection. <br /> Signe Title: aZ"C�'7 ­L Date: r �� <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTME T USE ONLY <br /> PHASE I <br /> Application Accepted'By l Date <br /> Additional Comments: <br /> Phase II Grout Inspection t k �h I Final Inspects n r <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 /> i BILLING REMITTANCE ti <br /> - BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> . FEE ' <br /> LESS <br /> PRORATION F <br /> PLUS <br /> PENALTY qk <br /> OTHER - <br /> OTHER <br /> Received by Date- - Recespt No. Permit No, - - iss ante Date-- - Mailed - Delivered - - -- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sar 2009 STOCKTON,CA 95201 <br />