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Applications Will Be Processed When Submitted Properly Completed. tse bure iosign inemppnvauvn. <br /> FOR OFFICE USE: � <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / V <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> 1 <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install theworkherein described.This application is d <br /> madryiin compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Qwrer's Name _ ral]C. �—�— -1 Phone '5 `ZZ <br /> �� .City <br /> Address <br /> license# 2_C), t�3 Business Phone <br /> Contractor's Name <br /> �- <br /> Contractor's AddressSZ =+ '�Sa��`~t ° fs"P 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 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ is <br /> REPLACEMENT❑ \ , -~ <br /> DISTANCE TO NEAREST: Septic Tank 10�?�-- Sewer Lines Pit Privy <br /> Sewage Disposal Field '�' Cesspool/Seepage Pit Other <br /> Property Line — Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> I ❑ CABLE TOOL Dia. of Well Excavation. lam <br /> i <br /> 13 INDUSTRIAL <br /> ® DOMESTIC/PRIVATE 13 DRILLED Dia. a Well Casing <br /> 11DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing -� <br /> 13 IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface.Seal Installed By: \ <br /> t <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> v PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> 1'1hereby 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 /> I 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 /> r 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 for a Grout Inspection prior to grouting and a final inspection. <br /> FI J <br /> i Date: <br /> Signed X Title: - <br /> k ` Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Pha II ut Inspection/ Phase If Final Inspection <br /> Inspection 13y f Date r✓ Inspection By Date <br /> ' By J <br /> Fee Is Due: E) ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t 8 ReceiveR M}Tuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4qS <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> ate 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 95201 <br />