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-�+ Applications11te Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> _FOR OFFICE`USE: APPLICATION ,,. ;; <br /> (For Non-Transferable, Revocable, Suspendable) ` k <br /> PUMP&WELL : 1 <br /> F ENVIRONMENTAL HEALTH PERMIT •1 r <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!5,ann'�ooaquin C�oount Cir nce N+o $62 and the rules and regulations of the San Jo ui L�If cal Health District. <br /> Exact Site Address <br /> —'F�'�� City/Town <br /> '— <br /> Owner's Name Phone <br /> Address City ! , <br /> Contractor's Name <br /> License#3��3 siness Phone„ Iv <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _7111 No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ "PRECONDIf ION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATIONU' PUMP REPAIR El <br /> REPLACEMENT❑ <br /> ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal I Field Cesspool/Seepage Pit Other <br /> Property Line/�� Private Domestic Well � Public Domestic Well <br /> INTENDED USE TYPE OF WELL o + <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> i ❑ DRILLED ,I <br /> DOMESTIC/PRIVATE t Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing " � <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ` <br /> a <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: 0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: _ ❑ State Work Done <br /> PUMP REPAIR: r❑ State Work Done <br /> k DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> I <br /> I hereby certify that 1 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 /> f <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c II for a Grout Inspection prior to grouting and a final inspection. f <br /> Signed X Title: —Q + �"� Dn Date: <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Il �v Date /I J <br /> _, �iuN <br /> Application Accepted Bys <br /> Additional Comments: <br /> � Phose 11 Grput Inspection Phasq��ll Frinal Inspection - <br /> �., �� Inspection By '�`,•1 Date <br /> Inspection B Date <br /> I 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 OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> E <br /> LESS <br /> PRORATION <br /> PLUS <br /> p{ PENALTY <br /> { OTHER <br /> 111' OTHER <br /> Received by -Date Receipt No. Permit No. Iss ante Date Mailed DeliveredS <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2044 STOCKTON,CZ).1 / <br />