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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> `❑ /a (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> i' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou ty Ordinance No.1862 and the rules and regulations of the San Joa ui Loc H alth District. <br /> Exact Site Address. �4 Y City/Town <br /> Owner's Name. Phone <br /> Address D City <br /> Contractor's Name License#i -moi Business Phone <br /> Contractor's Address r" Emergency Phone" 3 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):- <br /> NEW WELL❑ -.. DEEPEN ❑' _ RECONDITION 0" DESTRUCTION❑ -` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRE] } <br /> REPLACEMENT❑ `�l' <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 S <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 /> PUMP INSTALLATION: Contractor k! Lot, R77:42 <br /> Type of Pump H.P. `. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done °At Ob �J <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 /> Homeowner or licensed agent's signature certifies the following:1_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 In pec o ri Y o gr ting anV41nal-inspeclion. <br /> Signed le:. Dale: �" <br /> (Draw Ploon Reverse Side) <br /> f <br /> FOR DEPARTMENT USE ONLY } . <br /> PHASE I <br /> Application Accepted Byt� - Date <br /> Additional Comments: <br /> Phase II Grout Inspection h se III V iPal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE 1:1-EACH ❑ January 1 S Received By January 31 ❑July 1 &Received By July 31 <br /> REMIT <br /> BASE "EXPLANATION BILLING .. REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY. t <br /> OTHER <br /> OTHEn <br /> Received by Date Receipt No. Permit No._ s uan Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 952 <br />