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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> FOR OFFICE USE: r� ''APPLICATION <br /> r - (For Non-Transferable, Revocable,Suspendable)' <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ` <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY .I I <br /> I <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San oaq in C my Or inance No. 186 and the rules and regulations of the San Pquin L cal Health District. <br /> Exact Site Address .. . City/Town <br /> Owner's Name Phone 7 <br /> Address CItY j <br /> Contractor's Name License# Business Phone 2 3Cf�F' r n t <br /> Contractor's Address Emergency Phone O?� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No �l <br /> TYPE OF WORK (CHECK): NEW WELL�DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ZOO Sewer Lines '20© Pit Privy ' <br /> Sewage Disposal Field 2010f Cesspool/Seepage Pit Other <br /> Property Line �/a,52�or Private Domestic Well .2D Public Domestic Well <br /> . I <br /> INTENDED USE TYPE OF WELL <br />` © 3.DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing XI <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL f ACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION NARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> I PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Courtly <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <br /> s <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> r 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil all for a Grout Ins ction prior 10 grouting and a final inspection. <br /> Signed X _ Title: -'�r�t* ate✓ Date: <br /> 17 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ' Date 7_—_Z�—� <br /> Additional Comments: <br /> Grout I spection / Ph II Final In pection p� <br /> Inspection By Date— 7�a !/ Inspection By �`� Date �� G <br /> FeeIs Due: ❑ A ALLY ❑ PER UNIT C1 PER SITE El EACH El 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 AMOUNT <br /> . v d <br /> FEE c <br /> LESS <br /> PRORATION ' <br /> PLUS, <br /> PENALTY <br /> OTHER <br /> k OTHER --^- - <br /> Received by - Date Receipt No. Permit No, Is uance Dli --Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HA_ZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 _ <br />