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Applications Will Be Processed When Submitted Properly Completed. Besure Io sign IneAppnca11v11. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is I` <br /> made in compliance wjtl San Joa uin Count Ordina e N 862 a d the ru s and regulations of the San�JJo quip Local Health (strict. <br /> Exact Site Address - - lTown UQ <br /> Owner's Name O5� Phone <br /> Address City <br /> Contractor's Name -- License#��L� Q Business Pho e <br /> Contractor's Addressll� Emergency Phone w <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ p� W,-,_U5 ! <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 /> INTENDER USE TYPE OF WELL 1� . <br /> ❑ INDUSTRIAL ❑ 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> IND <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 19 Approximate Depth <br /> Describe Material and Procedure <br /> • <br /> I hereby certify that I have prepa d this application and th a work wit be done in accordan a with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> ii Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit <br /> i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor' firing or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is i su I s II em I per ns subject to workman's compensation laws of California." <br /> I will OTPI r a G t nsp ti n r to grouting and a final inspection. <br /> Signed X V/ Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> j Phase 11 Grout Inspection Phase I11 Final Inspection <br /> Inspection By Date Inspection By 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 /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION f� <br /> PLUS d <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> ry� <br /> Received by ate Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1604 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, �95201 <br />