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NPIcallonswill rteProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application, <br />�- FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL r <br /> (COMPLETE IN TRIPLICATE) \131"61 lGZZZ WATER QUALITY <br /> Application is hereby made totheSan Joaquin Lotal Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin County Ordinarjce No. 1862 and the rules and ulations of the Sa O Ruin t.ocaI Health District. <br /> Exact Site Address <br /> Owner's Name <br /> Address <br /> Phone <br /> City <br /> Contractor's Name License# "ry� <br /> lQ��� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION VN <br /> v <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ u <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> � Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing i�/J�1� <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION WROTARY <br /> 13 DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: kk <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H P <br /> PUMP REPLACEMENT: 13 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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. <br /> Homeowner or licensed agent's signature certifies the following:1 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 Ins ecti prior to grouting d a final inspection. I <br /> Signed X F Title: —�� <br /> Date: <br /> (Draw PI Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY- <br /> PHASEI <br /> Application Accepted By— <br /> Additional <br /> y Additional Comments: V Date p f <br /> sell rout Inspection q <br /> l inal Insp ction <br /> Phase !i <br /> Inspection By Date if-�� Inspection Byte <br /> Fee IS Due: 11 ANNUALLY ElPER UNIT ❑ PER SITE ElEACH ElJanuary 1 &Received By January 31 /❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED 7 <br /> FEE AMOUNT <br /> LESS 443 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> A IUZ:3 <br /> Received by Date J1 <br /> Permit NReceipt No. - <br /> P v. �Is uance D toMailed Delivered - <br /> _. APPLICANT—RETURN ALL COPIES TOr' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />