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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> ffFORFICE USE: <br /> APPLICATION <br /> (o IJ (For Non-Transterable, Revocable,Suspendable) / PUMP&WELL f I <br /> ----�"�- ENVIRONMENTAL HEALTH PERMIT ( 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, :. Fi ?t?}S[t� �r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaqu n County Ordinance 1862 and the,rules and regulations of the Sant Joaquin Local Health District. <br /> Exact Site Address City/Town i <br /> Phone �' _, <br /> r <br /> Owner's Name ~ �' 1 <br /> i _ T <br /> r : s Cjty '' <br /> Address <br /> Contractor's Name <br /> License# eft��! 4s -Tusiness'Phone <br /> .3 Emergency Phone <br /> Contractor's Address ^ <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK)- NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ - -WELL ABANDONMENT 110THER ❑ PUMP INSTALLATION ® _- PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 1:2)) <br /> — Cesspool/See a <br /> r Sewage Disposal Field - � e Pit Other p g <br /> Property.Line Private Domestic Well Public Domestic Well <br /> r INTENDED USE TYPE OF WELL 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �J T <br /> El DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C] 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 /> w«' <br /> Type of Pump - H.P. �✓ <br /> 11 State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP IR State Work Done <br /> s Approximate Depth ,, <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> S <br /> I 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 /> :"I certify that in the performance of work for which this permit <br /> Homeowner or licensed agent's signature certifies the following <br /> is issued, l 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 cerlifies the following:"I'certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensatiori laws;of California." 40 IA <br /> I will call for a Grout nspe tf pr' r to• uting and a sinal inspection. <br /> itle: Date: <br /> Signed X ` <br /> (Draw Plot Ian on Reverse Side) <br /> i k FOR DEPARTMENT USE ONLY <br /> a <br /> PHASE I Date <br /> Application-Accepted By <br /> Additional Comments <br /> Phase II Grout Inspection hase I11 Final Inspection <br /> Inspection-By <br /> Date <br /> Inspect ion B Date '�" Z— -- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 4❑ EACH, ❑ January'l & eceNid By-January 31 ❑ July 1 &ReCeiveRdEB�lTuly 31 <br /> EASE' 'EXPCAN'ATION r. BILLING REMITTANCE $ AMOUNT DUE -CHECKED <br /> �� DATE DATE REM177E AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> OTHER - A <br /> OTHER <br /> Received by Date ,Receipt NO: Permit No. I suanC Date Mailed Delivered' - - <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />