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a.Flcrr USE: pplicationsWillBe Processed When Submitted Properly Com <br /> FOR dspleted. Be Sure To Si-The A <br /> —APPLICATION pplication <br /> { <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) x 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 applicatio <br /> s made in-compliance with San Joa uin Count rdin a No. 1862 and a ons of the San Jo n is rules and regulations Exact Site Address quin L oat Health District. <br /> ( City/Town <br /> Owner's Name <br /> Address Phone <br /> F Contractor's Name City <br /> License� Business Phone Contractor's Address - <br /> Emergency Phone -- x <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X <br /> No <br /> TYPE OF WORK (CHECK): NEW WELLX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑REPLACEMENT❑ PUMP REPAIR <br /> a NP <br /> DISTANCE TO NEAREST: Septic Tank J o 4- t S <br /> Sewer Lines_6_0 Pit Privy <br /> I Sewage Disposal Fi�Id�Q0 r� _ Cesspool/Seppa e Pit —�.. <br /> Property Line g Other <br /> 1 _ Private Domestic Well _0 Public Domestic Well i <br />� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL FI ! <br /> P(DOMESTIC/PRIVATE Dia. of Well Excavation <br />�. ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing ti <br /> GRAVEL PACK <br /> ❑ CATHODIC PROTECTION Depth of Grout Seal <br /> ❑ DISPOSALROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 7. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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-o <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 signalure certifies the following.''I certify that in the performance of the work forwhich this <br /> permit is issued, I shall a ploy p ,/ T subject to workman's compensation laws of California." � <br /> I w' all for a ut I ectio o'r -grouting and a final inspection. <br /> Signed X { 1 <br /> Title: 41 Date: <br /> ( (Draw Plot Plan on Reverse S' ) <br /> } <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> Application Accepted By <br /> Additional Comments: Date <br /> Inspection <br /> Pha H Gro t _v <br /> Inspection By W ate )d2 7 Ph Ili Final Inspection <br /> Inspection By Date �Z2 <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 <br /> El July 1 &Received By July 31 <br /> BASE EXPANATION BILLING �. REMITTANCE $ REMIT t <br /> 1 DATE DATE REMITTED AMOUNT DUE CHECKED p <br /> AMOUNT <br /> FEE ' <br /> LESS <br /> PRORATION <br /> o 4 <br /> i <br /> PLUS r <br /> PENALTY <br /> OTHER \ <br /> OTHER <br /> —7 I <br /> r <br /> Received by Date - Receipt No. .� J^ <br /> P - Permit No. Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ Delivered /�!�/' <br /> 1 - 1641 E.HAZELTON AVE.,P.O.Box 201 STOCKTON_re os i Nf`S <br />