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1= <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> j(For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH`PERMIT <br /> WATER QUALITY , <br /> (COMPLETE IN TRIPLICATE) <br /> District install the work herein described.Thisapplication is <br /> Application is hereby made to the San Joaquin l Local Health <br /> } made incompliance with San Joaquin County Ordinance No. 1862 a d the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -S' City/Town _ <br /> Owner's Name v. �_:. t Phone <br /> d• s , -, <br /> Address City.r �; , . . <br /> Contractor's Name �'' License# � 7 Business Phone ' <br /> Contractor's Address <br /> e Emergency Phone ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK'(CHECK): NEW WELL❑ ' DEEPEN ❑ RECONDITION 13DESTRUCTION❑ " r <br /> WELL CHLORINAT,�ON NO WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ f <br /> REPLACEMENT� 6 <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 f ❑ DRILLED Dia. of Well Casing <br /> d 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 t +• Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumps H.P. <br /> PUMP REPLACEMENT: 3 ❑ State Work Done -� <br /> PUMP REPAIR: ❑ State Work Don_e., <br /> DESTRUCTION OF WELL: `' Welh.Diameter. '-xt ` w �—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-.,, I <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; 1-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]n the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." (i <br /> I will <br /> "call'fora Grout Inspection prior to grouting and a final inspection.''<'•- <br /> Signed X lz�rr�y� ��"'a' _f Title: .z Date: <br /> - {Draw Plot Plan on Rever a Sid +F <br /> FOR DEPARTMENT USE ONLY - <br /> r PHASE 1 1 <br /> Application Accepted By Date <br /> t <br /> ' Additional Comments: <br /> I Phase 11 Grout Inspection Pha I Final InsVection <br /> inspection By Date Inspection By .t ate <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT1 ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July'1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING z REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED u AMOUNT <br /> �FEESORATION <br /> •` PLUS -- <br /> PENALTY <br /> OTHER <br /> OTHER i _ ,..` - {. - -. _ - -- •` . <br /> Received by- - Date Receipt No. - I Permit No. - IS uanc to I Mailed - Delivered, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br />