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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: l APPLICATION !/ <br /> (For Non-Transferable,'Revocable,Suspendable) PUMP&WELL j <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE). WATER QUALITY <br /> , <br /> Application is hereby made to the San Joaquin Local Health District permit to construct and/or.install thework herein described.This application is <br /> made in compliance with San Joaquin County Or ' ante No. 18 22pd the rules and regulations of the SagJoaquin Local Health District. <br /> Exact Site Address ' ; City/Town <br /> Owner's Name - Phone <br /> Address `L/!J t r s City.. e <br /> Contractor's Name ; ,, L•icerise,# rlew) Busin ss P IQnet <br /> Contractor's Address `F Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK):_ 'NEW WELL❑ DEEPEN ❑ RECONDITIOND" DESTRUCTION❑ <br /> WELL CHLORINATION ❑ -WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIFE M <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 1 <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL lam' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOME=STIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 9 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing h <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ 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 /> 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, 1 shall not employ any person in such manner as to become subject to work man'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 /> I will call for a Gro 1 Inspection prior to grouting and a final inspec n. <br /> Signed X 22 , Title: Date: <br /> t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI lop <br /> Application Accepted By ,,. <br /> /ff: �. _ -..._,.... � .. - Date .. <br /> A <br /> Additional Comments: <br /> Phase II Grotit Inspection Ph a III,Final Inspection <br /> Inspection By Date - Inspection By / Date <br /> Fee Is Due: ❑ ANNUALLY [I PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION' .BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATEREMITTED ` AMOUNT ' <br /> FEE <br /> LESS' <br /> - PRORATION <br /> PLUS <br /> PENALTY, - <br /> OTHER <br /> OTHER <br /> Received by Date - - - --Receipt No. -Permit No. - Issuance Date , Mailed Delivered.: - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />