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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> F6R OFFICE USE: APPLICATION / <br /> (For Non-Transferable, Revocable,Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 111 f l <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County iOrdinance No. 1862 and t 'rules and'regulations of:the San Joaquin Local Health District. <br /> Exact Site Address��� �V - !Q City/Town <br /> Owner'sName �-SL_ �'�-` C K�1��� Phone <br /> Address City <br /> Contractor's Name License o Business Phone <br /> Contractor's Address - 42 0. . 4,4, �.+: � Emergency Phone <br /> I <br /> Is Certificate of Workman's Compensation Insurance ori File With SJLHD? Yes No aj <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - ` <br /> WELL CHLORINATION-E] WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 131--'PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �7 <br /> Property Line Private Domestic Well Public Domestic Well J <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN TRIAL ❑ 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 /> ❑ GEOPHYSICALw Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 0i <br /> PUMP REPAIR: ❑ State Work Done - --- S <br /> DESTRUCTION OF WELL: Well Diameter s Approximate Depth 0 r <br /> Describe Material and Procedure <br /> (27f <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." <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 or a Grout Inspe ion prior to grouting and a final inspection. h <br /> Signed Title: Date: <br /> 3 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted-By- Date <br /> ' Additional Comments: <br /> Phase II Grout Inspection III Final pection <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 <br /> REMIT <br /> _ BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY' <br /> OTHER <br /> OTHER - <br /> Received by Date Receipt No - Permit No. llssuanc*<Datd Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES X1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 <br />