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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> Ix (For Non-Transferable, Revocable, Suspendable) <br /> f <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> ('COMPLETE IN TRIPLICATE) WATER QUALITY F <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.Thl implication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health ii -application <br /> . 4 <br /> Exact Site Address <br /> /J City/Town <br /> Owner's Name A., <br /> Phone <br /> Addresses City — O <br /> Contractor's Namee Business Phone 7 { <br /> Contractor's Address 2 <br /> Emergency Phone T 0 E <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 0� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT El OTHER C1 PUMP INSTALLATION E] PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines. Pit Priv <br /> y .: . <br /> �a Sewage Disposal Field Cesspool/Seepage Pit Other <br /> " Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL di ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC i ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION fi° ❑ 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 Q' <br /> PUMP REPAIR: State Work Done ^�I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I havere ared this application P P pp cation and that the work will be done in accordance with San Joaquin County 4 <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, 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 subr=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 /> t <br /> I will call for a Gr ut InspeCtio prior to grouting and"a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted ByJ - paten <br /> Additional Comments: <br /> Phase III ��Ph�asGrout Inspection � nal inspection <br /> Fee Is Due: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. 13 January 1 &Received By January 31 ❑ July 1 &Received By J 1' <br /> Inspection By Date Inspection By Date 11 . <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> FEE (� 5c AMOUNT <br /> 1 777 ? <br /> LESS <br /> PRORATION <br /> I <br /> PLUS S <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 10 (JF <br /> II / 'r u r <br /> Received by Date :1 Receipt No. Permit No Issua ce Date Mailed Delgered <br /> APPLICANT-RETURN ALL COPIES Tot ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br /> '* —' <br />