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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> FOR oFFlce USE. APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> a ✓Y ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY �. .+ <br /> (COMPLETE IN TRIPLICATE) - ' ' i <br /> Application is hereby made to the San Joaquin Local Health District for a permit tocohstructand/orinstallthework herein described.This application is <br /> made in compliance with San Joaq in C my rdiQre NO. 1862 and the rules and regulations of the San Jo I alth District. <br /> City/Town <br /> Exact Site Address - <br /> >, .41 <br /> Phone— <br /> Owner's Name i <br /> City <br /> Address : <br /> " License Business Phone <br /> Contractor's Name <br /> v ZO <br /> Contractor's Address Emergency Phone No <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK):_ NEW WELL❑ DEEP 1:1RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ CCC��� ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Feld Cesspoo 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, Surface Seal Installed By: (L" <br /> PUMP INSTALLATION: Contractor <br /> + H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 i <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 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 Iaws of California." <br /> I tali f a nspeciion prior to grouting and a final inspection. A w <br /> Signed ell <br /> Title: Date: <br /> (DrawPlot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase I11 Final Inspection <br /> Phase 11 Grout Inspection <br /> Inspection By <br /> Date Inspection By -- Date <br /> s <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> REM TJuly <br /> MlTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> If (/3 <br /> FEE <br /> LESS ` <br /> PRORATION F <br /> PLUS ; 4 <br /> PENALTY <br /> OTHER t 6` <br /> OTHER <br /> E 6 X51 - Z <br /> Received by Date Receipt No <br /> No. Is ante ate Mailed vered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />