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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Fc ..OFFICE USE: APPLICATION <br /> (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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliancy with San Joaqu'n C unty rdin nc No. 1862 and the ru s an re uil ions o�the an Joaquin Local Healt District. <br /> Exact Site Address � S ( V S <br /> Owner's Name Phone r, `Lb 4 <br /> Address EZft2 City 4q=e=d=4 ' <br /> Contractor's Name License# D 1 Business Phone <br /> Contractor's Address Address Emergency Phone 6)0 7/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X 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 zm I 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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing (0 <br /> ❑ DOMESTIC/PUBLIC ❑{ DRIVEN Gauge of Casing �IflllL(�J <br /> ❑ IRRIGATION JA GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout z <br /> ❑ DISPOSAL ❑ OTHER Other Information enemaA <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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:"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 tilic 11 for a Grout Inspe 'on pri o grouting and a final inspection. <br /> Signed X Title: 6� Date: <br /> (Draw Piot Plan on lievqga Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -- <br /> Application Accepted By �� Date 3�pp �l <br /> Additional Comments: <br /> Phase II Grout Inspection hase 111 Final Inspection <br /> Inspection By Date Inspection ByDate <br /> a.,'1 a A- .a-rte. d9 B. <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASF EXPLANATION AMOUNT DUE CHECKED <br /> PATE PATE REMITTED <br /> AMOUNT <br /> FEE 8' � {�3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 AYE.,-P.O.Box 2009 STOCKTON,CA 95201 <br />