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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -►.VOR OFFICE USE: APPLICATION <br /> ell (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 JoaquinCounty Ordinance.No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> ,Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address �/ .?S-0 tA,Z AU City �+ <br /> Contractor's Name License If -73?3 Business Pho �_Iz .7S <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONN❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER D OPUMP 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 <br /> ❑ USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> u DOMESTIC/PRIVATE ❑ DRILLED` Dia. of Well Casing l <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 Seal Installed By: <br /> PUMP INSTALLATION: Contractor V <br /> Type of Pump H,P_ �+ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: tate Work Donen <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate 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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework forwhich 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 forwhich this <br /> permit is issued, I shall employ p p y 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 /> Signed X eA., _ L4- ._ Title: Date: JC� - <br /> (Draw Plot Plan on Reverse Si e <br /> FOR EPARTMENT USE ONLY <br /> PHASEt <br /> Application Accepted By Q Date <br /> Additional Comments: <br /> Phase II Grout Inspection ' h e I final Inspection <br /> Inspection By Date Inspection BY�� �' Date 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Pr PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE > <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered " <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH.PER MIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 952CIl �� <br />