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Applications Will Be Processed When Submitted Properly Completed. <br /> FOR OFFICE USE: APPLICATION <br /> ,: - (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ®�— <br /> I Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install thework,herein described.This application is <br /> f made in compliance wi h Sa Jo quip County Ordin n e N�. 1862 and the r les nd egu ations ff he San Joaquin Local Health District. <br /> Exact Site Address D S Cjt~own <br /> Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name License Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation I surance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1113DEEPEN ElRECONDITION❑ DESTRUCTION 11PUMPREPAIR❑ <br /> WELL CHLORINATION U1 WELL ABAN ONMENT OTHER PUMP INSTALLATION ❑ GJ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank -4 Sewer ILines _�y Pit Privy <br /> _ Cesspool/Seepage Pit Other <br /> Sewage Disposal Fuld <br /> Property Line/0 * Private Domestic Well Q{Public Domestic Well <br /> INTENDED USE TYPE OF WELL �f {r <br /> 1:1 INDUSTRIAL CABLE TOOL Dia. of Well Excavation a ¢ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing I i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing G t� �!►,r�u)� <br /> IRRIGATION <br /> ❑ 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 /> r <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 Californiai <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich ths <br /> permit is issued, l shall employ per s subject to workman's compensation laws of California." <br /> II for Gr t I ecti or to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse ide) <br /> r <br /> n{� FOR DEPARTMENT USE ONLY <br /> PHASE I L,IU, _ © j j� <br /> Date <br /> Application Accepted By. UCS rte-ti <br /> Additional Comments: - <br /> se II out Inspection se I I Final Inspection �� f <br /> Inspection BI. <br /> y Date Inspection y Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &-Received By January 31 .❑ July 1 &Received <br /> R MlTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER <br /> 1 suance Date Mailed elivered <br /> Received by Date Receipt No. <br /> Permit No. D <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 f.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA <br /> i <br />