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Applications Will Be Processed Whel4_Subniitted Properly_Gompleted. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ---12 <br /> (COMPLETE IN TRIPLICATE) rWATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joa_uin County Ordinance No. 1862 and the rules and.regullationsAof the Sa oaquin Local Health District. <br /> Exact Site Address T City/Town <br /> Owner's Name Phone 3 ;2�_s� <br /> Address c - City <br /> Contractor's Name 'License# j 5�-. <br /> .�Z, r�L Business`Phbne_ <br /> Contractor's Address :: � :'Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONDESTRUCTION❑ 1 ,, I <br /> WELL CHLORINATION 13 WELL ABANDONMENT 1:1 OTHER El PUMP INSTALLATION ❑ PUMP REPAIR 1:2 <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 /> ❑ IN TRIAL ❑ CABLE TOOL Dia, of Well Excavation. Jr <br /> _ <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing .J <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal J <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information LA <br /> ❑ GEOPHYSICAL Surface Seal Installed By: i <br /> PUMP INSTALLATION: ContractorlizO <br /> Type of Pump - e. H.P. I C <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 `/1 <br /> 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. it <br /> i Home owner or licensed agent's signature certifies the following:g g g:'9 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 /> C r a Grout Inspection prior to grouting and a final inspection. k fL 1 i <br /> Signed `Y1� 'k, .�� <br /> 9 ._ Title: —_ Date _' <br /> (Draw Plot Pllan,on Rei erse Side) <br /> w FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By r Date <br /> Additional Comments: <br /> Pha II ut-inspection a Plia final Inspection <br /> Inspection By Date Inspection By Date i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑'PEH 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 /> 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y <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 AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> u- <br />