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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 /> Y ENVIRONMENTAL HEALTH PERMIT ' <br /> WATER QUALITY .. <br /> (COMPLETE IN TRIPLICATE) y:. i:# t -� . ;r ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance w' h Saoa u,in County r - ance No. 18U and the s and regulations of the San Joaquin Local Health District. <br /> ExactSite Address City/Town ~ <br /> Owner's Name - Phone <br /> Address a = .... City <br /> z. <br /> Contractor's ame ! License# p �� BusingSs PhPUP <br /> 1 <br /> Contractor's Address " " Emergency Phone /y r 7.4 ."• ' <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes 1_— No <br /> TYPE OF WORK (CHECK): NEW WELL❑' DEEPEN ❑ RECONDITION❑ -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTO' <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 r <br /> INDUSTRIAL ❑ 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. Surface Seal Installed By: <br /> 3 <br /> PUMP INSTALLATION:, Contractor t: <br /> Type of Pump H.P. . <br /> I' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done i <br /> k <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t a 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 /> 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 for a Grout Inspection prior to grouting and a final inspect' <br /> Signed X Title: Date: ` <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE <br /> E ApplicationAcceptecl By ' Date <br /> Additional Comments. <br /> Phase 11 Grout Inspection — Phase II Final Inspection <br /> Inspection By_ <br /> y Date- drispection f31 Date <br /> Fee IS Due: 11 ANNUALLY '°❑ PER UNIT '❑'PER SITE""` ❑'EACH ❑ January:l &Received By January-31 ❑ July I &Received By July 31 <br /> REMIT <br /> ' BASE -'EXPLANATION - - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATIONi- <br /> � . W <br /> PLUS 4 <br /> PENALTY - i , <br /> OTHER <br /> f <br /> OTHER �. <br /> i s <br /> E .Received byDate:� -.Receipt No... <br /> Permit No.s.-_ _ M Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />