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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTneAppticaxion <br /> FOR OFFICE USE: APPLICATION (� / <br /> r <br /> I'll, (For Non-Transferable, Revocable,Suspendable) PUMP&WELL / <br /> ENVIRONMENTAL HEALTH PERMIT / (/ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San J uin County Ordinance No. 1$62 and the r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name - Phone 3 Z <br /> Address - City <br /> Contractor's Name License# ��'`fg2/ Business Phone Q16 <br /> Contractor's Address Emergency Phone _e� /'� I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No (n <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONO 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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t 'Surface Seal Installed By: <br /> PUMP INSTALLATION: f Contractor <br /> Type of Pump—its � H.P._ / <br /> PUMP REPLACEMENT:; ❑ State Work Done O <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,Iand rules and regulations of the San Joaquin Local Health District. r <br /> Horne 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." <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 /> s I will call for a Groat Inspection prior to grouting and'ajfinal inspection. <br /> Title: �,.. J Date: �'� ��� <br /> Sl�rd-X I 'y c(Draw:Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �f <br /> Application Accepted By Date <br /> Additional Comments: <br /> i Phase It Grout Inspection P�1 Fina Inspection <br /> Inspection By Date Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ 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 DATE REMITTED AMOUNT <br /> FE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ♦ Received by Date Receipt No. Permit NO. Issuance DAe Mai$ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />