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r_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE-r-` APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thisa plication is <br /> made in compliance with San Joaquin ounty.Ordinano.,4862 and the rules and regulations of the a Joaq in Local Health Distric <br /> Exact Site Address �� City/TowneV. <br /> - r i <br /> i Owner's Name Phone <br /> Address %e- City <br /> Contractor's Name C YLL if if License# Busi s P one <br /> Contractor's Address s4Qaq s Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> I TYPE OF WORK (CHECK): NEW WELX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ ; <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lilies �� .:Pit Privy <br /> Sewage Disposal Field °" �'Cessp oQSeepage-0it Other <br /> Property Line Private Domestic Well ...��'�_ Public Domestic Well <br /> INTENDED USE T TYPE OF WELL �t _ <br /> ❑ I DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �4 <br /> ❑ DOMESTIC/PUBLIC1❑ DRIVEN Gauge of Casing <br /> El IRRIGATION lxc IGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OTARY Type.of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t 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 /> 1 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 /> Home owner 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 Californias;:,,' <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that imtlie.perforrnance of the work forwhich this„ <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will calf for a Gr ut Inspecti in prior to groutigg and a final inspection. <br /> t. 1 <br /> Signed X Title: - I , Date: <br /> (Drdm' Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE & QX _ <br /> Application Accepted B Date t <br /> Additional Comments: <br /> t _ <br /> P se 11 Grout Inspection gas li F' al Inspection <br /> Inspection By ate Inspection By Hate <br /> f, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 . ❑ JuEy 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMDUNT DUE CHECKED <br /> r <br /> AMOUNT <br /> FEE . <br /> LESS t4 <br /> PRORATION <br /> PLUS <br /> PENALTY l <br /> t. <br /> OTHER �4 <br /> OTHER - �- <br /> r - <br /> 72 F <br /> R r r M <br /> Re eived by oath Receipt No. Permit No, I suance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,-P.O.Boa 2005 STOCKTON,CA 95201 - <br /> Y y <br />