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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r — (For Non-Transferable, Revocable,Suspendable) <br /> 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 with San Joaquin County Ordmancp rJo. 1862 and theules and regulations of the Sa�nj)oaquin Local Health Distri t. <br /> Exact Site Address — City/Town <br /> Owner's Name I Phone <br /> Address City <br /> Contractor's Name . License# c2!W F13 Business Phone _5 5-/ 5_ ) <br /> Contractor's Address ; 11 X70[ 7.grgency Phone � _41,2 7/ ._ <br /> Is Certificate of Workman's CompensationIns rance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C] <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank X Sewer Lines Pit Privy <br /> Sewage Disposal Field &X" ' ' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done Cn <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �N <br /> Describe Material and Procedure 4:11 <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. <br /> Home owner 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 persons subject to workman's compensation laws of California." <br /> I will all for a Grout Insp9lon prior to grouting and a final inspection. S7 <br /> Signed X Title: Date: 1 .31 <br /> (DragPlot Plan on Reversebide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B Date <br /> Additional Comments: <br /> 5*r <br /> Rase 11 Grout Inspection i PhaseIIIFinal Inspection <br /> Inspection By Date� _� Inspection By `I Date _I_nL <br /> Fee IS Due: 0 ANNUALLY I❑ PER UNIT ❑ PER SITE 12"EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> @ l AMOUNT <br /> FEE _�- <br /> LESS ! <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHE <br /> ceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />