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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> s <br /> ENVIRONMENTAL HEALTH'PERMIT 1 w <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Y aw <br /> .. <br /> Application is hereby made to the San Joaquin Local Health Di strict fora pe rm it to constru ct and/or install the work herein described.This applIctition is <br /> made in compliance with San Joaquin County Or inance No. 1862 a the rules and regulations of the San,4oaqyjn Local Health District. <br /> Exact Site Address 7.J' City/7own p <br /> Owner's Name ` <br /> i Phone <br /> Address l city .v <br /> Contractor's Name '`� License#IC1�3 73 'Business Phone- J <br /> Contractor's Address 0 :21 " � Emergency Phone <br /> G 2 <br /> t1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �_ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 „• , ` <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMEST16PRIVATE ❑ DRILLED j Dia. of Well Casing <br /> ❑ p C/PUBLIC ❑ DRIVEN Gauge of Casing Y <br /> IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> CATHObIG'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. / LI <br /> PUMP REPLACEMENT: ❑ S}ate Work Done <br /> PUMP REPAIR: 1 r State Work!Done -49 <br /> DESTRUCTION OF WELL: `-WelhDiameter Approximate Depth <br /> Describe.fUlatenal and Procedure L t <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 mannesr..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." l�). <br /> E ` <br /> I all r a Gro spection prior grouting and a'final insp ion. <br /> Itle: Date: <br />- signed X -, -, <br /> (Draw Plot Plan on Revers ide) ' <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I - <br /> ApplicationDate Accepted By + <br /> Additional Comments: <br /> Phase 11 Grout Inspection s III Final InspectioVceived <br /> lnspection By <br /> Inspection By Date �u ' <br /> —Feels-DUE:-O-'ANNUALLY` ❑ PER IiNIT— -13"PER SITE '�❑ EACFi'i' ]January 1"S Received By January 31}` —I� July 1uly 31 � <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED AMOUNT <br /> i <br /> FEE <br /> LESS <br /> PRORATION ' <br /> " PLUS <br /> PENALTY <br /> OTHER <br /> _ 4 <br />}� OTHER <br /> c a <br /> r�_�-`Received by Dates, Receipt-No W- -Permit No.- - - is uance ate I Mailed Delivered - <br /> PA P,�ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />