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Applications Will Be Processed When Submitted Prope r>itylld. ro�gn Application. �[ <br /> FOR OFTICE USE: APPLICA MW <br /> w (For Non-Transferable, Rev e, Su��s��pp1endagqble) [s�� <br /> ENVIRONMENTAL HEALTH*I�B�LN W 1981 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALI9AN JO , <br /> Application is hereby made to the San Joaquin Local Health District for a permit tocon�tf (q�f�lf�Lh n escribed.T 's application is_ <br /> made in compliance with S J aq�iin�ounty d Hance 1862 and a rules an o s o i oc t ' <br /> Exact Site Address ff�� City/Town <br /> Owner's Name Phone r <br /> Address � City <br /> Contractor's Name icense# usin s Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �t <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 /> ❑ 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 Surface Seal Installed By: �1 <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH P• P�YISN <br /> VPUMP REPLACEMENT: 11State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 /> Home owner 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 no mploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contra I or sub-contr let' nature certifies the following:"I c l that in the performance of the work forwhich this <br /> p it i iss e , I shat employ p rsons ubject to workman's compens tf laws of California." <br /> I will o nspection prior t routing and a final inspecti s <br /> Signed XTitle: Date: l <br /> (Draw Plot Plan on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY l <br /> i <br /> PHASE I <br /> Application Accepted By �'"`� ©� Date <br /> Additional Comments: <br /> Phase II Grout Inspection se 11 Final 1 ection�'y ¢/ <br /> Inspection By Qn In Date Inspection By ate''`! `42 V f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />