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:-ref 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 theSan Joaquin Local Health District fora permit toconstructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordnance No. 8 and the rules and regulations of the Sante oaquin Local Health District, <br /> Exact Site Address- City/Town <br /> Owner's Name o. <br /> Phone <br /> Address City <br /> Contractor's Name - �L>�1 ��, - � ' License Business Phone 'f - 1 <br /> Contractor's Address jl to Emergency-Phone U <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): -NEW WELL❑ DEEPEN'[:]'; RECONDITION 11-- DESTRUCTION❑ ;--� - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION © UMP REPAIR❑ / <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy S— <br /> c <br /> -Sewage Disposal Field Cesspool/Seepage Pit Other f <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND STRIAL © 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 13.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 <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 /> Homeowner 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 forwhich this <br /> permit is issued,! shall employ persons subject to workman's compensation laws of California." <br /> I will c r Grout Inspection prior to grouting and a final inspection. <br /> Signed X - .Title. erir- Date: 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f / <br /> Application Accepted By -.. / ( <br /> _ _ Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectionh III Final Inspection <br /> Inspection By. Date Inspection By , Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE' ❑ EACH, ❑ January 1 &Received By January 31 ❑-July t 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATEON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE' ,5, r <br /> �4 <br /> 1 <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> Received by Date- Receipt No. Permit No. - Issuance -ate Mailed Delivered ;. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />