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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 G�- <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> rictftira permit to construct and/or install thewvrk herein described;This application is <br /> Application is hereby made to the San Joaquin Local Health Dist1862 and then rules and regulations of the San Joaquin Health District: <br /> made in compliance with San Joaquin County Ordinance No. <br /> City/Town <br /> Exact+Site Address <br /> .. . Phone <br /> Owner's Name -.�- <br /> City z <br /> Addresst <br /> Contractor's Name c? License# + Business Phone <br /> Contractor's Address Emergency Phone T, <br /> r �-� N o <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): "NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN O <br /> WELL CHLORINATION 1:1 WELL ABANDONMENT ❑ OTHER 13 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 /> ,. _,�LADED USE TYPE OF WELL <br /> l!f INBi75TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0/DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> �D MESTIC/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 SurfacSeal Installed By: <br /> PUMP INSTALLATION: Contractor 1 <br /> Q � <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done �] <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 /> 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." z <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this r <br /> permit is issued, I shall employ persons subject to"workman's compensation laws of California." ` <br /> a r a Grout inVection prior to grouting and a final inspection. <br /> X <br /> a 4 Title: -��'w_ Date: <br /> Signe <br /> (Draw Plot Plan on Reverse Side) l <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE I Date <br /> i Application Accepted By. <br /> Additional Comments: <br /> Phase II Grout Inspection '+ Phase I al Inspection <br /> t Date Inspection By Date <br /> Inspection By <br /> By J <br /> Fee-is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receip REMITuIy 31 <br /> BASE EXPLANATION Bli-UNG _ REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> e <br /> FEE l <br /> LESS " <br /> PRORATION <br /> PLUS - <br /> PENALTY i <br /> OTHER <br /> r- <br /> OTHER <br /> Received by <br /> Date Receipt No, Permit No. Issuance Date Mailed Delivered - <br /> 1501'E.HAZELTON AVE.,P.O.Bol 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />