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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 District for a permit to construct and/or install the work,herein described.This.application is <br /> made in compliance with Soman Jfoaquyin County Ordi ance No. 1862 fan/d the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 'o 'd yLi Litt [ Lei City/Town <br /> Owner's Name , � Phone r <br /> Address city 'a� <br /> Contractor's Name 1 License# Business Pharie�' � � <br /> Contractor's Address VIP, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑'`- DESTRUCTIO,N,❑/ <br /> WELL CHLORINATION ElWELD ABANDONMENT ❑ x OTHER ❑ PUMP INSTALLATION Its PUMP REPAIR❑ r+(�� <br /> REPLACEMENT❑ V 1 <br /> DISTANCE TO NEAREST: Septic-rank Sewer Lines Pit Privy <br /> :i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> OMESTIC/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: i Contractor_ �-V­if. t. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: l ❑ State Work Done - <br /> PUMP REPAIR: '! ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. <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, 1 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 for a Grout Inspection prior to grouting and a final inspection. -- t <br /> Signe Title: Date: 7 <br /> I� (Draw Plot Plan on Rev rse Side) <br /> I <br /> . � R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: I <br /> Phase 11 Grout Inspection has I Final Inspection <br /> -, �Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY 111,PER UNIT ❑-PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July'31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> to DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 ; <br /> Received by Date ,w - Receipt No. Permit No - Issupricebate -Mailed Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />