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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ._ ENVIRONMENTAL HEALTH PERMIT q.— ' <br /> ds <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 the rulesa regulations of the San aquin Local Health District. ' <br /> Exact Site Address h e-I- City/Town <br /> Owner's Name { Phone <br /> Address City <br /> Contractor's Name LicenseJk� . `Business Phone <br /> Contractor's Address Emergency Phone "}' _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION13 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION 6— PUMP REPAIR ( L� <br /> REPLACEMENT❑ V- <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 /> ❑�,�IN TRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> rDOMESTIC/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 Sep[ Installed By: <br /> PUMP INSTALLATION: Contractor 4, � .2 <br /> Type of Pump -[.cry H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done Q Z <br /> PUMP REPAIR: ❑ State Work Done`' <br /> DESTRUCTION-OF WELL: Well Diameter Approximate Depth t <br /> • Describe Material and Procedure <br /> Qd <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County at <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 C2Vor a Grout Ins ction prior to grouting and a final inspection. <br /> Signe X � Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> b- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection PhaaWlIvinal Inspe on <br /> Inspection By Date Inspection By Date J <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH _❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> f REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. <br /> AMOUNT <br /> FEE <br /> 5 i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. - l6suate Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES r 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> I <br />