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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> T (For Non-Transferable, Revocable,"Suspendable) PUMP&WELL <br /> ii <br /> ENVIRONMENTAL- HEALTH PERMIT <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 describe d.This application is. <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San,d}oaquj,n Local Health District. <br /> Exact Site Address City/Town <br /> i <br /> Owner's Nalite Phone' <br /> Addresses , .� City r. _ I <br /> LicenseY#�� Business Phone <br /> Contractor's Name = � � <br /> Contractor's Address /30 ' r = iEmergencyPhone' ��"`�� <br /> i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r� No <br /> TYPE OF WORK {CHECK}:}~ NEW WELL❑ "DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ / <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR M- D� i <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation j <br /> 19-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 42) <br /> - Type of Primp q_e� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appirox4nate.Depth <br /> Describe Material and Procedu e-" <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 3 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." - <br /> 1 <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 w)q call for a Grout I pection prior to grouting and a final inspection. <br /> I: t; <br /> Signed X itle: Date:.. <br /> r <br /> (Draw Plot Plan on Rev rse Side) <br /> 4.1 <br /> _T! K <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By yy Date -- <br /> 'tr <br /> Additional Comments:- <br /> Phase II�Grout inspection Phe III Final Inspection <br /> - Inspection By Date: Inspection By D <br /> Fee Is Due: ❑ ANNUALLY i ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 04 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT t <br /> 4' FEE <br /> LESS <br /> PRORATION h <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER <br />� t <br /> .. . . I4 7) 1 l �L `�� <br /> Received by Date- Receipt No. -- -Permit No. Issuance Date Mailed Delivered Il <br /> .�' -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMrriseRVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9M <br />