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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR✓�FFICE USE: 3 APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) / PUMP&WELL <br /> I r <br /> ENVIRONMENTAL HEALTH PERMIT <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 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address // City/Town <br /> Owner's Name 1`h/ Phone 3.2 <br /> Address S~ !� city <br /> Contractor's Name /� �-S 'License# l��Z--% Business Phone - - I <br /> Contractor's Address 1. 2 Emergency Pho e <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No o <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION' DESTRUCTION❑" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ' <br /> REPLACEMEN <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 /> ❑ INDUSTRIAL Q,CABLE.TOOL_ v _ y Dia. of Well Excavation l <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 /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ,'State Work Donees— <br /> DESTRUCTION OF WELL: Well Diameter �. Approximate Depth <br /> i 1 <br /> Describe Material and Procedure <br /> I hereby certify that l 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c for a Gro t Insp c ion prior toigrouting and a final Inspection. <br /> Signed X Title: r Date: <br /> g (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASEI <br /> Application Accepted By Date ' <br /> Additional Comments: a <br /> Phase 11 Grout Inspection 4 ► e Al Final I ection <br /> ✓= 6—�/ <br /> Inspection By Date Inspection B to y I <br /> PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31— ❑ ,July 1 &Received By July 31 <br /> Fee Is Due: 11 ANNUALLY ❑ I <br /> REMIT <br /> BASE EXPLANATION 13ILLING REMITTANCE $ AMDUNT DUE CHECKED <br /> DATE" DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS \ ,r'" .�., s•;,. <br /> PENALTY <br /> OTHER e <br /> OTHER <br /> Permit No. Issuan Dat _ Mailed Delivered <br /> Received by � Date �- � Receipt No. � - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH iy11T/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOGKTON,CA 9521 <br />