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y Applications Will Be ProcessedWhenSubmittedProperlyC.omplereo. oe aure 1oalgn 1Fiemppncalwn. , <br /> FOR OFFfCE USE: — APPLICATION f <br /> (For Non-Transferable, Revocable,Suspendable) "` <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> � ' <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) + <br /> work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the <br /> made in compliance with ,}oac�uin C u Ordinance No.1862 and the rules and regulations of the San Joaqui Loca Health District. <br /> Exact Site Address +. It <br /> m City/Town <br /> 729- <br /> Owner's Name r Phone <br /> Address / City <br /> Contractor's Name License# O usiness Phone <br /> Contractor's Address Z Emergency Phone <br /> Is Certificate of Workman's Compensation Ins rance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLZ��DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ SIMV <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR f r <br /> REPLACEMENT 11 /Q <br /> DISTANCE TO NEAREST: Septic Tank / Q Sewer Lines Pit Privy <br /> _/ <br /> Sewage Disposal Field Cesspool/Seepage it Q- ' Other <br /> Property Lin '"Private Domestic Well ZjQ7f_-- Public Domestic WeII <br /> INTENDED USE TYPE OF WELL <br /> ❑,�, INDUSTRIAL ZUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> Z <br /> ,ffUMESTIC/PRIVATE ❑BILLED Dia. of Well Casing �L <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing G <br /> ❑ IRRIGATION 0 G. EL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 60-ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Offer Information <br /> ❑ GEOPHYSICAL Wface Seal I stalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ��� H.P. L� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - p roximate 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 <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 mariner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f: <br /> I w' II for G ns lion prior to grouting and a final inspection. <br /> Signed X Title: -f �retl Date: <br /> i (Draw Plat Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I pL <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P a III F" I Inspection <br /> Inspection By Date . Inspection By �'" _. Date �l <br /> I 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 /> �Q -DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> ' PLUS <br /> PENALTY <br /> OTHER <br /> F <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Da a Mailed Delivered <br /> �. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �' 1601 E.HAZELTON AVE.;P.O.Box 2009_ STOCKTON,CA 95201 <br />