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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, f <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ' <br /> 'PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San J aqum Co my Ordina c_e No. 2 d the rules and regulations of the Sar�Joaguin al Health District. <br /> Exact Site Address City/Town � 7 ^{ <br /> Owner's Name 0. Phone J`^ <br /> AddressA City <br /> Contractor's Name ` License# / Business Phone ,1. r�g _� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran a on File With SJLHD? Yes_.1� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <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 <br /> ❑ 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F 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 /> IIE is issued I shall not employ an person in such manner as to become subject to workman's compensation laws of California.' <br /> P Y Y <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 /> 1 11 f a 1rouLinspction or to grouting and a final 'inspection. <br /> Signed X r Title. _ AF Date: 3 ea�,2' r <br /> ' (Draw Plot Pian on Reverse Side) <br /> y �^7-4FOR DEPARTMENT USE ONLY AM, <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection se III Final Inspection pp d <br /> Inspection By Date Inspection By Date R-1C pp__Oz_ <br /> 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'DUF CHECKED <br /> DATE DATE REMITTED Oa AMOUNT <br /> f <br /> 1 <br /> FEE <br /> LESS <br /> k PRORATION € <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -� Date Receipt No. Permit No I uance Datel Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - _ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />