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I� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> . ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&1NELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqui n Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or inance No. 18 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact;Site Address City/Town <br /> �j <br /> Owner's Nam Phone <br /> Address City <br /> 31 <br /> Contractor's Name License# 0 usiness Pho <br /> Contractor's Address s Emergency Phone f <br /> Is Certificate of Workman's Compensation I14rAnce on File With SJLHD? Yes No <br /> TYPE..10FWORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELLi CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E3-- PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> li Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ II O' USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/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 /> l� Type of Pump ! dOAF.PUMP REPLACEMENT: El State Work Dane C>b <br /> PUMP REPAIR: ❑ State Work Done <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 /> II 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 /> I is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> k 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." <br /> I will c a Grout Inspecti pri to grout! and a final lnspection. <br /> i; <br /> Signed X Title: % Dale: <br /> f1 (Draw Plot Plan oneverse Side) <br /> �l FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> ilApplication Accepted By <br /> ti 6 g� - � Date to��� v <br /> Additional Comments: <br /> i Phase II Grout Inspection Ph III Final Inspection U <br /> Inspection By Date Inspection By Dat J� <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> 'E BASE EXPLANATION AMOUNT DUE CHECKED <br /> I.PRORATION DATE DATE REMITTED AMOUNT <br /> FEE. �..,LESS <br /> i'PLUS <br /> PENALTYI <br /> i OTHER <br /> OTHER`' qy� <br /> Received t y` Date Receipt No. Permit No. Mailed Deliverea <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Boz 2 09- STOCKTON,CA 95201 <br /> t S <br />