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� - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE.USE:, APPLICATION <br /> - (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co nty,Ordinance No. 1862 and the rules and regulations of the San Paquin Local Health District.. <br /> Exact Site Address Cy City/Town C <br /> , �C, ? "'.`7 r 3 <br /> Owner's Name ��� Phone <br /> Address r City-: <br /> Contractor's Name License# Business Phone <br /> Contractor's Address / 3 0 + Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): .. NEW WELL❑ DEEPEN❑ RECONDITION❑ 'DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION El PUMP REPAIR❑ <br /> REPLACEMENT❑ N I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines` ( Pit Privy )t <br /> Sewage.Disposai - — -Cesspool/.Seepage-Pit. Other w <br /> i. Property Line Private Domestic Well Public Domestic Well ! i <br /> INTENDED USE TYPE OF WELL <br />' INDUSTRIAL _ ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC_/PRIVATE �' 11 DRILLED Dia. of Well Casing <br /> ❑ DO�7ESTl6/PUBLIC ' ❑ DRIVEN Gauge of Casing <br /> F RIGATION 13GRAVEL PACK Depth of Grout seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout . <br />` ❑ OTHER Other Information <br /> ❑ DISPOSAL "�"�... �C <br /> ❑ GEOPHYSICAL S rface Seal Installed By: <br /> /� two <br /> PUMP INSTALLATION:' s ,' Contractor <br /> i <br /> Type of-Pump T�rr��,-Krs�L H.P. . J <br /> . PUMP REPLACEMENT: -❑ Stake Work-Done-_- r - -- -_.._._-- - ;-- �� i <br /> PUMP REPAIR: ®tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r. <br /> I hereby certify that I have prepared this application and that the work-will be done in accordance with San Joaquin County <br /> f 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 .k <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 orsub-contracting signature certifies the following:y'I'certify that in the performance of the work for which this <br /> I permit is issued, i shah employ persons subject to workman's compensation laws of California." ` <br /> I Willi for Grout Ins ion prior to g outing and a final inspectiorii f3 Z�,� <br /> Dater <br /> F Signed X ills: - <br /> IP (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G Ir Date �� <br /> F Application Accepted By <br /> ' Additional Comments: <br /> Phase Il G ou '1 eciion III Final Inspection <br /> ffL <br /> Inspection By ate t Inspection By Date <br /> r <br /> Fee Is Due: E.] 'ANNUALLY ❑-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> r BASE EXPLANATION, BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS -r- - - <br /> PENALTY <br /> OTHER ` <br /> OTHER <br /> Received by Date Receipt No, Permit No. - /Issuafte Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 >' <br />