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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFRCE USE: I APPLICATION <br /> —"� - ( /0 JOS (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 /> a made in compliance with San Joaquin Count Ordinance No. 1862nd the'rules'and regulations of the San Joaquin L Health District. <br /> Exact Site Address d -' City/Town 6 !� <br /> I Owner's Name " -To +a /1 Phone <br /> f Address — �-a c� er ? City +' <br /> Contractor's Name JE=4644 �+s License# 21r_ Business Phone - <br /> t Contractor's Address t Emergency Phone <br /> I is Certificate of Workman's Compensation Insurance on File Ith SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN © RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ Pump"#tEPAIR18 C� <br /> REPLACEMENT❑ <br /> x DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field —Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Weil Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION Cl GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 111 ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT:. T❑ State Work Done <br /> PUMP REPAIR: D9 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter- Approximate Depth <br /> Describe Material and, Procedure <br /> 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. t,„ <br /> 4 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit u, <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'shiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspect' p 'or gr ting an a final Inspection. <br />,. Signed _. i#le: <br /> Date: +t I <br /> (Draw Plo an on Reverse Side) <br /> F <br /> A FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE <br /> Application Accepted By - `^ Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection ByM"N C Date Inspection ByN . C�' Date <br /> ( <br /> Fee Is Due: ❑'-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 <br /> i. BILLING REMITTANCE $ - REMIT <br /> BASE EXPLANATION DATE GATE REMITT AMOUNT DUE CHECKED <br /> / AMOUNT <br /> - FEE .._ - S . <br /> LESS <br /> PRORATION <br /> i PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER y <br /> 1! <br /> Received by Date Receipt No. Permit No. - Iss n e Datb Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,,P.O.Box 2009 --STOCKTON,CA 95201 <br />