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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign ineApptTGa[Ion. <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtiora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaq i County Ordinance No.1862 and the rules and regulations of the San Joaquin ocal H alth District. <br /> Exact Site Addre s O Cityl7awn <br /> Owner's Nam Phone <br /> Address City <br /> P C fa �- <br /> Contractor's Name / License# Business Phone 4d<34— 9f39 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance n 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 REPAIR❑ <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 /> I& 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 SurfaQ Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 1 <br /> Type of Pump P.—,—� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 ar 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." <br /> r <br /> 1 ill call for Grout inspect" prior to ung and a final Inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C <br /> Application Accepted By Date <br /> �--- <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAC ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> EASE EXPLANATION ILLI RF�AkTTANCE $ AMOUNT DUE CHECKED <br /> n, DA / 1L DATE REMITTED AMOUNT <br /> FEE {� � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> HER <br /> LHER <br /> Received by Da Receipt No, Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />