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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �FOR OFFICE USE: <br /> APPLICATION <br /> (Far Non-Transferable, Revocable,Suspendable) PUMP&WELL <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 and the rules and regulations of the San Jo a Lo al Health District. <br /> Exact Site Addressa 2 d Imo+'+!t City/Town <br /> Owner's Name Phone <br /> a �G an 4e City <br /> Address <br /> Contractor's Name Ao Z_&) License# � ��u <br /> 7siness Phone <br /> Contractor's Address Aa Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 2!,- _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER ElPUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy y <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other t <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1P DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> 13 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL_ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: —Contractor ' <br /> Type of Pump ✓r� f H.P. <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 /> I hereby certify'that I have prepared this application and that the work will be done in accordance with San JoaquI <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 performance of the work for which tis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of CContractor's hiring or sub-contracting signature certifies the following:"i certify that in the performance of the work for <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspectio ri to gr ting an a final inspection. <br /> Signed X Title: R., Date: 3 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments:__�y <br /> f Phase If Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &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 /> Iva- <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER <br /> 69`Zn 3 B <br /> i <br /> Issuance Date Mailed Delivered <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601 E.HA2ELTON AVE.,P.O.Baa 21709 STOCKTON,CA 9520 <br />