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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> FOR OFFICE USE: APPLICATION \� <br /> 4- (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquinunty Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Q City/Town <br /> Owner's Name VAC; Phone 54— d IZ <br /> Address � M �-.� � � City <br /> Contractor's Name D 1 License#� � �7 3 BusinessPhone <br /> Contractor's Address 114 `Yf, X is s c� Emergency Phone �a• 9 r. .Z.r t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yesy No ~ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESI f D <br /> WELL CHLORINATION C1 WELL ABANDONMENI� OTHER 13 PUMP INSTALLATION❑ PUMP REPAIR Vt� <br /> REPLACEMENT Lam" <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines— Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> _ 1 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ~ <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED p` 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 -Su rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - // <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: EYState Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter CDll — 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 1/r <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 laws of California."1 <br /> I will II for Grout Ins ection prior to routing and a final inspection. �� <br /> Signed X 1'Title: —'.;'7 11.,- Date: ✓ �'� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 'f I t t <br /> Application Accepted By C� �� i Dater f <br /> Additional Comments: uv <br /> PhaII G out Inspection P se III Final Inspection <br /> se <br /> Inspection By Date Inspection ByDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> q� DATE DATE REMITTED AMOUNT <br /> FEE <br /> "I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Jssluai4ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />