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ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) �j � <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL J rx <br /> ' u <br /> (COMPLETE IN;TRIPLICATE) WATER QUALITY +� <br /> Application is hereby made tothesanJoaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with Soman Joaquin Coty G) di ce 7 2 and the rules and regulations of the San uip Local Health District. <br /> Exact Site Address ��.. City/Town <br /> Owner's Name Phone <br /> Address <br /> Contractor's Name License# 49V Business Phone-3 loq-,:a -7 7? <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes >4__—."__ No <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ fl <br /> ,t <br /> DISTANCE TO NEAREST: Septic Tank lV,10 Sewer Lines Pit Privy <br /> Sewage Disposal Fiel5' f�a Cesspool/Seepage Pit Other <br /> Property Line 410 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ]A-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 Or <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout .V <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surgace Seal Installed By: C!� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ZaA H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 01/ Approxim to 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 /> ac <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 41 _ <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 8 <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 fallowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." �, 1 <br /> 1 will c II for a Grout Inspecti n prior to grgpting and a final Inspect'o <br /> Signed X R9lN Title: -_ Date: d c 7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D lp <br /> Application Accepted By ` Date b-it 'COI <br /> Additional Comments: <br /> ase II' t Inspection �f Q�O Aeceived <br /> a a III Final Inspection <br /> Inspection By e v t� Inspection Date U� <br /> d <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & January 31 ❑ July 1 &Received By Jufy 31 <br /> REMIT <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 ,1 <br /> OTHER .� ^ w <br /> 13�5� 10�1s'ceDai <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />