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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION A_jr 40--B iJ <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT �I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit h San Joaquin County Ordin rice N 1862 and the rules and regulations of the Sa._Joaquin Lo al Health District. <br /> Exact Site Address ! � ( �� City/Town <br /> Owner's Name � �� �'� ' . � '. Phone <br /> rr <br /> Address _ 4=7_ 8 City. —�d-<.� <br /> Contractor's Name License��-21 Business Phone' T l <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fi With SJLHD? Yes No �} <br /> TYPE OF WORK (CHECK): -NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN,❑ <br /> El11YJ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION - PUMP REPAIR {�yt <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 TYPE OF WELL <br /> ❑ ISTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> , <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 Surfkce Seal Installed By: <br /> PUMP INSTALLATION: Contractor-ro <br /> Type of Pump , ��� H.P. 237,A.Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done --j <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and.Procedure n <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 for which this ' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will r a Grout In prior to grouting and a final inspection. ` <br /> Signe _ Title: ] -c l�--i -.-- Date: r�r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE r <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha ilial Inspection <br /> Inspection By Date Inspection By ( Date 5 <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. _ Iss nce D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />