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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. { <br /> FOR OFFICE USE: APPLICATION i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT S <br /> i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San�Joaquin Local Health District for apermit too nstructand/or install the work.hereindescribed,This.application is <br /> made in compliance wi n Jo q ou ante No- 18 J a <br /> .62 and the ul nd regulations of the San quih Local Health District. <br /> Exact Site Address �� t City/Town <br /> Owner's Name I s :. Phone <br /> Address li' City <br /> Contractor's Name i, License#172JW40' Business�Phone' - 1 <br /> Contractor's Address ' Emergency Phone f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW;(WELL❑ ` `DEEPEN ❑ RECONDITION❑ DESTRUCTION 1:1 - — - <br /> WELL CHLORINATION E] WE LL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO.NEAREST: SeptiN Tank Sewer Lines Pit Privy <br /> x- <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Propeirty Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL I : ❑ 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 S face Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. d <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 /> '±e <br /> F <br /> hereby certify that I have prepared this appiication 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. r <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 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 persons subject to workman's compensation laws of California." i <br /> I ° <br /> I will call for a Grout Inspection prior to grouting and a final insnerJjon. <br /> Signed X Title: Date:J10 <br /> II (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE I - Date <br /> R , w <br /> Application Accepted By ' - ?� <br /> Additional Comments: iM r <br /> Phase.`ll Grout Inspection h rg�Ifllffll inspectionInspection By ` Date Inspection By� 0 Date.- <br /> Fee Is"Due: ❑ ANNUALLY OPER UNIT ❑ PER SITE ❑ EACH' ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION - <br /> BILLING REMITTANCE $-'. DATE DATE REMITTED AMOUNT DUE CHECKED F I <br /> I� AMOUNT <br /> I� I <br /> . FEE 7/ ' <br /> LESS I� <br /> PRORATION <br /> PLUS y <br /> PENALTY �p ' <br /> OTHER <br /> i <br /> 1 OTHER <br /> I� � 3 '72 <br /> Received by - Date �li� - - Receipt No. - Permit No. - -- lssuan e Dale Mailed _ -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Boz 2009 STOCKTON,CA 95201 <br /> IM <br />