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W Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j s <br /> FOR OFFIf E usE: APPLICATION j <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installtheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and th rules and regulations of the Sa Joaquin Local Health District. <br /> � City/Town <br /> Exact Site Address ,07 <br /> t <br /> s <br /> Phone <br /> Owner's Name < <br /> City <br /> AddressBusiness Phone <br /> Contractor's Name ' License#� <br /> ` c <br /> Contractor's Address -- �( _0 Emergeny Phone No <br /> Is Certificate of Workman's Compensation Insurance on,File With SJLHD? Yes ,�,�r' <br /> TYPE OF WORK (CHEM WELL ABANDONMENT ❑ELL 0 'DEEPEN ❑ OTHERRECONDITION <br /> ❑ ITI PUMP DESTRUCTIOINSTALLATION N6' PUMP REPAIR❑ <br /> WELL CHLORINATION 1 <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field I <br /> Property Line Private Domestic Well Public Domestic Well 4 <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation ` <br /> LISDOMESTIC/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 <br /> ❑ OTHER Other Information <br /> j [1 GEOPHYSICAL Surface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor <br /> P. <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> E PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 <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 will call r Grout Ins p tion prior to grouting and a final inspection. r� y <br /> Title:. Date: ' 'J <br /> Signe •_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> FApplication Accepted By <br /> Additional Comments: <br /> P;d, I Final Inspection �9 <br /> Phase Ii Grout Inspection r/ pate <br /> j Inspection By <br /> Date Inspection By <br /> ❑ Ool <br /> R UNIT ❑ PER SITE 13 EACH ❑'January i &Received By January 31 July 1'&ReceivedByJuly 31 <br /> Fee IS Due: ❑ ANNUALLY PE <br /> 1 BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY' <br /> l OTHER <br /> OTHER <br /> jpaleReceipt No. Perrnit,No. Issu nce Date Mailed Delivered <br /> Received by' 1501 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,_CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES �31k_ <br />