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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> i, (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> I? ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) . I WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 thq rules and regulations of the San Joaqui Loc H alth District" <br /> Exact Site Address, City/Town <br /> Owner's Name 41".i v►; At�paei o✓ Phone <br /> Address City <br /> Contractor's Names License#/� Business Phone <br /> Contractor's Address - 6i,� 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❑ DESTRUCTION❑ I <br /> WELL CHLORINATION 1:1 WELL ABANDONMENT 1:1 OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR. <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ' Pit Privy d <br /> f Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> is ' <br /> INTENDED USE TYPE OF WELL <br /> - <br /> ❑ INDUSTRIAL r ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED a Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONh - ❑ GRAVEL PACK Depth of Grout Seal <br /> 3, <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Typerof Grout <br /> ❑ DISPOSAL i3 ❑ OTHER 3 Other Information <br /> ❑ GEOPHYSICAL = ) Surface Seal Installed Bay <br /> PUMP INSTALLATION: Contractor '"`- <br /> i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: �I ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter BApproximate Depth <br /> II -Describe Material and Procedure <br /> i? k <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 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." t <br /> I will call for a Grout Inspecti n ri r ting an final inspection. <br /> i � <br /> Signed itle: Date: <br /> (Draw Plot an on Reverse Side) <br /> zly <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I li _ y-�3— <br /> - Date — --- <br /> Application Accepted B <br /> Additional Comments: <br /> Phase II Grout Inspection -4 { Phase III Fid el Inp�ection <br /> Inspection B r " Date �Z <br /> Inspection By Date P y <br /> Fee Is Due='❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11-EACH ElJanuary 1 &Received By January 31 El July 1 8 Received By July,311 <br /> - _ -- - REMIT <br /> P. BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> I DATE p DATE REMITTED AMOUNT <br /> e <br /> FEE ly <br /> LESS I� <br /> PRORATION! ' <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />