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Lr Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, t <br /> F, ,;E. APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) ' <br /> PUMP&WELL _r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE 1N TRIPLICATE) <br /> ' <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install theworkhereindescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and,regulations of the San Joaq in Local Health District. <br /> Exact Site Address City/Town j <br /> Owner's Name - <br /> Phone <br /> Address aCity <br /> Contractor's Name P License#s57-gjO '/,3 Business Phone <br /> k <br /> Contractor's Address M R Emergency Phone - x <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X _ No "V <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Q) <br /> DISTANCE TO NEAREST: Septic Tank / i'1 Sewer Lines Pit Privy _ t r_ <br /> Disposal Field Cesspool/Seepage Pit Other 77 Well— <br /> Sewage <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL N <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> rt <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ElDRIVEN Gauge of Casing <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information d <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.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 /> 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit D <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, I shall employ persons subject to workman's compensation laws of California." <br /> I Mfflall for a Gro Inspec' n prior to grouting and a final inspection. (//1, <br /> Signed X Title: = ,u Date: <br /> (Draw Plot Plan on Re rse Side) <br /> FOR DEPARTMENT USE ONLY , <br /> 1� <br /> PHASE I <br /> Application Accepted By � � r eon - Date �� <br /> Additional Comments: <br /> Phase tl Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By 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 REMITTEDAMOUNT <br /> . <br /> FEEe <br /> LESS <br /> ° PRORATION <br /> PLUS <br /> �! ! <br /> PENALTY <br /> { OTHER <br /> f OTHER d LJ �� ' j'1•j/t ��^ <br /> Yn <br /> Received by Datel Re eipt No Permit No. suanc Date Mailed Delivered <br /> APPLICANT—RETURN ALC COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sax 2009 STOCKTON,CA 95201 <br />