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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR ol1cE usE; APPLICATION <br /> row (For Non-Transferable, Revocable, Suspendable) 1 S <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) �sCWATER QUALITY <br /> Application is hereby made to the an 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 Jo uin Co t Or 'nance No. 1862 en r and regulations of the San Joaquin Local Health District, <br /> Exact Site Address an-or i l y ! �' �� City/Town <br /> Owner's Name Phone <br /> Address ' City_. C _ I <br /> Contractor's Name -t` Rer� ;ECONDITION <br /> nse# Business Phone �- <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With D? Ye _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ❑' 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 1 <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 Surfaipe Se tailed By: �tf <br /> PUMP INSTALLATION: Contractor m <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. s <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 shalt 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 issued, I shall employ persons subject to workman's compensation law's of California," <br /> I 'll all for a rout Inspection prior uJili a f' al inspeccttion. If <br /> Aq <br /> Signed Xe: Date: , <br /> (Draw Plot on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph a III al inspection ` <br /> Inspection By Date Inspection By 1 Date 'g <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �- <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. 'Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />