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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign ThApplication. <br /> f FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT v <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe 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 an Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address_ � T Lt� City/Towii <br /> Owner's Name irLt Phone <br /> Address ' City <br /> Contractor's Name License Business Phone, <br /> Contractor's Addresser, o _ Emergency Phone L. 1. . . <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No d" <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION 1313Z <br /> 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 :i TYPE OF WELL <br /> ❑ IND TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> © IRRIGATION II ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL . l< Surface Seal Installed By: <br /> PUMP INSTALLATION- Contractor <br /> Type of Pu p_�Q H.P. /t <br /> PUMP REPLACEMENT: ,. 11 State Work Donees <br /> PUMP REPAIR: ❑ State Work Done .� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure D6 <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."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." l/} <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 w5AaMPr a Grout Inspection prior to grouting and a final inspection. + <br /> Sign _._- "._ Title: - ___ Date: - <br /> i (Draw Plot Plan on Reverse Side) <br /> a : ; FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ���!/�. Date / <br /> Additional Comments: � <br /> Phase 11 Grout Inspection h ell rtal Inspection ¢� <br /> yl� <br /> Inspection By Date Inspection B .� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE ll' EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _...,. AMOUNT , <br /> FEE z/ �- <br /> 4 <br /> LESS 31, <br /> PRORATION - <br /> PLUS <br /> PENALTY !] <br /> OTHERz <br /> OTHER °F <br /> I! <br /> Received by Date Receipt No. Permit-No .. Issuance 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 />