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" "*_A p cations Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppucanon <br /> FORj0FFICLEUSdE: . APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r <br /> s app <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalitheworkhereindescriealthDitrict.cation is <br /> ` made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local <br /> Health District. <br /> Exact Site Address L a, City/Town <br /> , <br /> Owner's Name ax& Phone <br /> Address �f City <br /> Contractor's Name �' ' ' � � License# 7/ Business Phone <br /> ! Contractor's Address ' f Emergency Phone <br /> h Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION X PUMP REPAIR❑ <br /> REPLACEMENT❑ f <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 /> �` ❑ DRILLED pia. of Well Casing <br /> �„DOMESTIClPRIVATE p� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 13 IRRIGATION ` 13 GRAVEL PACK Depth of Grout Seal <br /> C ❑ ROTARY <br /> ❑ CATHODIC PROTECTION Type of Grout <br /> ❑ DISPOSAL w _0 ❑ OTHER Other Information �{ <br /> 11 GEOPHYSICAL ;- * # „ ti 1.5 c Surface Seal Installed By: <br /> PUMP INSTALLATION: v" T Contriinctory <br /> ti• `Type of Pump H.P. <br /> PUMP REPLACEMENT. ❑ State Work'Done~` i <br /> PUMP REPAIR: ❑ State Work Done t <br /> " ar ,i <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> i <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: 4 certify that in the performance otthe 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." <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 tf 11 for a Grout inspection prior to grouting and•a Ahil inspection. r y' <br /> jTit}e::•'.. Date: <br /> (Dravr"1214at-Plan-on.-Reverse Side) <br /> �FDEPARTMENT_PSE ONLY ,# <br /> 1 , <br /> I PHASE I rn�Cn Date <br /> Application Accepted By <br /> �, <br /> Additional Comments: _.__ ` ' .–�° _- <br /> ` _ Phase II Grout Inspection ? //�� ,,Pha__se II Final Inspection <br /> Date Inspection By sl�aeni� Date <br /> Inspection By _r" ' <br /> { <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec,iped By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ' G BILLING REMITTANCE 1 $ AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATiF REMITTED AMOUNT <br /> J <br /> ;EE <br /> S <br /> PRORATION ` <br /> w <br /> PLUS f <br /> i PENALTY j - <br /> F OTHER <br /> OTHER .. <br /> 1. <br /> Received by Date Receipt No. _Permit o.% Issuance Date Mailed Deli red <br /> IT'/,SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM <br />