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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFRICE USE: APPLICA 1 ION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I` PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 wi an Joa uin Go ty Ordin e o. 1862 and a rules and regulations of the San Jo I Loc H alth District. <br /> Exact Site Address d City/Town <br /> Owner's Name i� /f�/ il[ Phone r. <br /> Address City <br /> I Contractor's Name License `rereusiness Phone <br /> Contractor's Address Emergency Phone <br /> t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No As— <br /> TYPE OF WORK (CHECK): NEW WELL24' � DEEPEN 11 RECONDITION 11 DESTRUCTION <br /> F WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION 2� - PUMP REPAIR❑ <br /> REPLACEMENT❑ r . _ <br /> DISTANCE TO NEAREST: Septic Tank `sewer Lines Pit Privy <br /> Sewage Disposal Field ` Cesspool/Seepage Pit Other <br /> Property LineZ-15'f Private Domestic Well p Public Domestic Well �4n474. <br /> INTENDED USE _ 3 TYPE OF WELL. > a <br /> ❑ INDUSTRIAL ❑ CABLE TOOL` Dia. of Well Excavation <br /> ❑ D9ME5TiC/PRIVATE- BILLED Dia. of Well Casing �fl ► <br /> ®/DOMESTIC/PUBLIC~ ❑ DRIVEN Gauge of Casingy�- <br /> ❑ IRRIGATION © GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL f �F ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfac�q_Seal Instal d By: <br /> PUMP INSTALLATION: Contractor �! ie <br /> Type of Pump �`�Cf -x S;+ H.P. <br /> PUMP REPLACEMENT: ' ❑ State Work Done . <br /> PUMP REPAIR: t K ti © State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth , <br /> r Describe Material and Procedure <br /> s <br /> I hereby certify,that`l have prepared this application and that the work will be done in accordance with San Joaquin County a <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 p p y persons subject to workman's compensation laws of California." <br /> I f a o t l ection, rior to grouting and a,final inspection. <br /> Signed Title: Date: rC:�0 <br /> (Draw Plot Plan on Reverse ide) <br /> F <br /> FOR DEPARTME USE ONLY <br /> PHASE I t /f I 111 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase It Grout Inspection Phase III f=inal Inspection <br /> Inspection By. { Date Inspection By Date <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT 1 PER SITE ❑ EACH? ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ' REMIT t <br /> BASE P EXPLANATION BILLING REMITTANCE $ <br /> DATE ► DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> r i <br /> FEE <br /> LESS 1 <br /> PRORATION <br /> PLUS i. <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - 7 6scl�D (0 <br /> Received by Date Fleceipt No. - Permit No L Issu nce Date Mailed Delivered <br />' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />