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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR-OFFheE USE: APPLICATION <br /> ` (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> i .. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' (COMPLETE 1N TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oa in Local Health District. <br /> Exact Site Address 22 City/Town <br /> Owner's Name Phone <br /> Address "2-2 City2� <br /> Contractor's Name License#�_ Business Phone <br /> Contractor's AddresEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No .� <br /> TYPE OF WORK (CHECK): NEW WELA* DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIO15 <br /> 51 PUMP REPAIR❑ Qp.J`t <br /> REPLACEMENT❑ 7� <br /> f 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 71 <br /> :DOMESTIC/PUBLIC ElDRIVEN Gauge of Casing <br /> r.; <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 19 OTHER ""���,Q, <br /> Y `�—;''-0 Other Information V <br /> ❑ GEOPHYSICAL �.(`„�•' Surface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor <br /> k <br /> Type of Pump +a.�.� H,P. <br /> PUMP : r'R� I' State Work Done_ � — � <br /> PUMP REPAIR: i ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I .. <br /> Describe Material and Procedure <br /> - r <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 /> k Nome owner or licensed agent's signature certifies the following:"I certify that in the performance of the 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 /> t 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, I sha'll employ persons subject to workman's compensation laws of California." <br /> fI will c II for a G !Inspection prior to grouting and a final inspection. ` <br /> Signed X Title: pate: q�r 2 17� <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> PHASE H �zj <br /> Application Accepted By Date <br /> i <br /> Additional Comments: <br /> I Phase II Grout Inspection ,,/ P III Finan ection <br /> Inspection By Date /" Ic Inspection By ate <br /> E <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE 1:1 EACH ❑ January i &Received By January 31 El July 1ved By'July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE - CHECKED <br /> €. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER' <br /> OTHER <br /> I <br /> Rece'sved by Date, Receipt No. .Permit No. I"suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .V 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> it <br />