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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE FN TRIPLICATE) WATER QUALITY „ <br />,..Application is hereby madeto theSa.n Joaquin Local Health Districtfora permitto construct and/or install theworkherein descritied.This application is + <br /> made in compliance with San Joaquin C unty Ordinance o. 1862 and the rules and regulations of the San Jo uin L 'Cal Health District. <br /> Exact Sit Address t � City/Town 4� e <br /> Owner's Name '; ' .+rte Phone -A <br /> Atddress .. 9 City o' • <br /> 'Contractor's Nam 4 License# Business Phone <br /> Contrra�ctior's Address 4 Emergency Phone <br /> 1.5-Certificate of Workman's Compensation Insurance on File Wi# SJLHD? Yes� No <br /> TYPE WORK (CHECK): _ NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy („ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f 1 <br /> Property Line Private Domestic Well Public Domestic Well r <br /> INTENDED USE r TYPE OF WELL <br /> ❑ INDUSTRIAL V ❑ CABLE TOOL Dia. of Well Excavation i <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I] CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER ! Other Information <br /> ❑ GEOPHYSICAL Surface Sea stalled By: ) <br /> PUMP INSTALLATION: Contractor <br /> • <br /> Type of Pump G{ /yyYr6F/ H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth 1 <br /> Describe Material and Procedure <br /> 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance ofthe work for which this permit <br /> is issued, 1 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 /> 1 Wil call'for a Grout Inspection prior t4routing.a d a final Inspection. ; <br /> Signed l a "ki ,itle: �- _�� Date: �v <br /> (Draw Plot Vlan on Reverse Side) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By eDate <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By IVB 1 n Date Inspection By Date - 2 <br /> . f <br /> Fee Is Due:-[:] ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 S Received By July 31 f <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT s <br /> FEE' Ch <br /> LESS <br /> PRORATION I <br /> -. PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> } i <br /> /s-�� z� <br /> a Received by Date Receipt No. Permit No. Issuance Mte Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />