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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppucauon. <br /> FOR OFFICE USE: APPLICATION �- <br /> (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 installthe work herein described.This application is <br /> made in compliance wig a aquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (�`-iI City/Town <br /> �] f �C�7� <br /> Owner's Nami Qr� Phone ► R --` <br /> City <br /> 1 <br /> Address City <br /> f r <br /> Contractor's Name License# usiness Phon <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensatio nsurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO ❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT El OTHER 11 PUMP INSTALLATION PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic'Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ St�Work Done <br /> .., <br /> PUMP REPAIR: �State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 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 i issued, I shall employ persons sub'ect to workman's compensation laws of California." <br /> il.- <br /> I will It for a Grout Inspectio PIrior to outing and a final inspection. <br /> Signed X Title: Date: <br /> x (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY pp Q11 <br /> P /SEI <br /> Application Accepted Zil <br /> Date <br /> Additional Comments: <br /> Grout Inspection hase 111 Final In pection <br /> Inspection By Date Inspection By T Date <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 /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuance Date Mailed Defivered <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISEAYICES <br />