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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OFFICE USE: APPLICATION + <br /> .off (For Non-Transferable, Revocable, Suspendable) l <br /> PUMP&WELL <br /> Y 4 ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 and the rules and regulations of the San 0aq l9 Local Health District. <br /> Exact Site Address -f—/16 City/Town <br /> Owner's Name Phone <br /> &P j <br /> Address DS City ^� <br /> Contractor's Name License If 'fir♦ Business Phone 4 RIT917 "t] <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <br /> REPLACEMENT❑ i <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 /> �❑ [2�MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r 1� 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 F--e^ ©' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . ❑ State Work Done <br /> PUMP REPAIR: 1/ ® State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County U <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout Inspectla r ting and a final iAspeciiQn. <br /> ) Signed X 4 � �r Title: Date:)- <br /> (Draw <br /> ate -(Draw Plot Plan on Reverse Side) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> Application Accepted By Date <br /> �1 <br /> Additional Comments: - - <br /> F Phase II Grout Inspection a I�IFIIpection p <br /> r Inspection By Date Inspection By Date <br /> k <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 /> 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ( OTHER <br /> OTHER `''3 <br /> Received by :Date Receipt No. Permit No Issuance Vale Mailed Deiivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />