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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - ' <br /> FOR OFFICE USE: APPLICATION - \� <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT / PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �+1 ,�a <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 Joaquin Cou Ordinance No. 1882 and th ruleF,and regulations of the Sa e3 in Local He Ith District. <br /> Exact Site Address i <br /> i City/Town G � kf—" <br /> Owner's Name IF <br /> Phone pLl <br /> Address City <br /> r <br /> Contractor's Na "" icense#Ua Q 3�i � / Business Phone <br /> Contractor's Address Emergency Phone — LS <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 9-- DEEPEN ❑ RECONDITION❑ DESTRUCTION-5— <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0pUMP 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 <br /> ��— Dia. of Well Excavation <br /> �QMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing S �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION �iOTARYi' <br /> Type of Grout r <br /> ❑ DISPOSAL ❑ OTHER Other Information L. p <br /> ❑ GEOPHYSICALur # <br /> fac Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump— L Nr�c • H.P. <br /> PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 fallowing:"I certify that in the performanceof the work forwhich 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." 4 <br /> Contractor's hiring or sub-contrac ' signature certifies the following:"I certify that in the performance of the work forwhich this <br /> Perm <br /> it is issued, I shall employ p rso subjoct to workman's compensation laws of California." <br /> will call for a Gr Ins r r to routing and a final inspection. <br /> Signed X <br /> t ,z <br /> Title: {1 Date: <br /> (Draw Plot Plan on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted By "WM" (a/A -0, 1 _ <br /> Dat" <br /> Additional Comments:.13h -- �- - <br /> ase II Grout Inspectionat Inspection f <br /> Inspection B Date Inspection By A2 <br /> Date S ��3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 r <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PATE REMITTED <br /> AMOUNT <br /> FEE + r� Ap 0 <br /> LESS vv a# <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> 3 <br /> OTHER <br /> OTHER <br /> ReceivedbyD to I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2oo9 STOCKTON,CA 95201 <br />