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Applications`Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> a (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �l <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 San Joaquin County Ordinance No. 1862 and4he rules and regulations of the San Joaquin Local Health'District. <br /> Exact Site Address 4 LQ R,0—,Ja_.4 , City/Town . <br /> ^� it s <br /> Owner's Name 1iry, p ` -�( .�� k r' Phone 4_— _ <br /> Address C/1- City <br /> Contractor's Name �_ Pie` T License# � f BusinessPhone <br /> Contractor's Address P.O. I `~ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes ���� No <br /> TYPE OF WORK (CHECK): NA WELL❑ DEEPEN ❑ RECONDITION❑ IDESTRUCTIO,,N O <br /> WELL CHLORINATION El WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION 4 PUMP REPAIR❑ <br /> REPLACEMENT El <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 i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INND STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L.►rDOMESTIC/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 c Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done/ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTIONOF 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,iF nd 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:1 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' t <br /> I will for a Grout Inspection prior to grouting and a final inspection. <br /> Signed � 1 Title: r� <br /> Dater <br /> " <br /> !� (Draw Plot Plan on Reverse Side) <br /> !II FOR DEPARTMENT USE ONLY <br /> it <br /> PHASE 1 �� <br /> Application Accepted By Glued DateL <br /> Additional Comments: <br /> Phase II Grout Inspection a III Fin ection/"r <br /> Inspection By �`' Date Inspection By to <br /> Fee Is Due: ❑ ANNUALLY JL❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> $ REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED f AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> 4 <br /> Received-by Date J1, Receipt No. - Permit No. issue a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES~ 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201' <br /> 0. __ 1 <br />