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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQFI,.OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL C <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fpr a permit to construct and/or install the work herein described.This application is x <br /> made in compliancetrt n utn C ty Ordinance No. 1862 and es and regulations of the San Jo uin Local Health District. <br /> s <br /> Exact Site Addres �a ,- ' City/TownG2 J"� <br /> Owner's Nam ! Phoner - <br /> Address City �-y <br /> Contractor's Nam Lice ns Business Phone ! S-5 - <br /> Contractor's Addres MS X• ic'6cZ73 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ LH D? Yes No e-r-r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION UMP REPAIR C1 <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 r <br /> ❑ IN USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I�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 Sur P Seal Installed B y <br /> PUMP INSTALLATION: Contractor <br /> a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. '1 <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 /> per/iq, issued, I shall employ persons subject to orkman's compensation laws of California." <br /> I III c�ll for a Gro 1 Inspection pr' r t ;�groutin and a final ins ton. <br /> Signed X ` Title Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By /// Date / <br /> Additional Comments: <br /> Phnase Grout Inspection Phase III Final Inspectio C <br /> Inspection By Iv/ Date Inspection By f r�'`� � Date �F0 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED Q� AMOUNT <br /> FEE S ry L1L5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. 0 Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �r 0601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />