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Applications Will Be Processed When Submitted ProperlyCompleteO.Tse sure Io,Ign r11w•+r•I•••�••• <br /> FOR OFFICE USE: APPLICATION <br /> J� (For Non-Transierable, Revocable, Suspendable) PUMP &WELL <br /> y I,l <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY I <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application Is <br /> made in compliance with San�Joa Joaquin in Local <br /> n County Ordinance No. 1&62 and the rules and regulations of the San Joa u �ealt a District. <br /> ` City/Town <br /> Exact Site AddressN� ROP❑ <br /> Phone <br /> Owner's Name i City <br /> Address Business Phone_ 94 l <br /> Contractor's Nam Licen <br /> envy Phone <br /> Contractor's Address No V <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL91--DEEPEN ❑ RECONDITION❑ DESTRUCT ION �. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION&-PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ rQ Pit Privy <br /> Cesspool/Seepage Pit Other <br /> Cess <br /> Sewage Disposal Field P <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL l <br /> IJ INDUSTRIAL C3 CABLE TOOL Dia. of Well Excavation �. <br /> ®OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d; <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0--ROTARY Type of Grout <br /> ❑ DISPOSAL 13OTHER Other Information <br /> ❑ GEOPHYSICAL �z. Surface Seal Insta led By: <br /> PUMP INSTALLATION: Contractor /� <br /> k H.P. <br /> Type.of Pump <br /> • PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: '❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coulvty <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 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 ca for a Grout Inspection prior to gro ti and a final inspection. <br /> �i3v'A <br /> Title: Date: <br /> Signed X <br /> I (Draw.Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: I <br /> Phase 111 Final Inspection <br /> Phase II Grout Inspection Date <br /> Inspection By Date' Inspection By <br /> Fee Is Due: 13 ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH El Jany i &Received By January 31 ❑ July 1 &Receiv July 31 <br /> REMIT <br /> BILLING RE TAN E, REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> BASE EXPLANATION DATE AT <br /> Cha <br /> FEE &� <br /> LESS ,s- y <br /> PRORATION, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No Permit No. Iss an a Date Mailed Delivered <br /> El - Received by # Date �— <br /> ` APPLICANT—RETURN ALL COPIES TO''�`ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />