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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> FOR OFFICE USE: APPLICATION , <br /> (For Non-Transferable, Revocable, Suspendable) <br /> .PUMP&WALL � <br /> ENVIRONMENTAL HEALTH PERMIT n,}�IJ� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto constructand/or install the work herein described.This application is <br /> made in compliance wit n Jo n Cq ty Ordi IaQC5,N0.78 2 and les and regulations of the Say <br /> qAJnaguin LocH0 Ith District. <br /> Exact Site Address City/Town 4 <br /> rOF <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name se# Business Phone ^� <br /> Contractor's Address 7Ernergency Phone <br /> Is Certificate of Workman's Compensation Ins_ urarace on File With 5 LHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL t?/ ❑ RECONDITION DESTRUCTION❑ RC1 <br /> WELL CHLORINATION ❑ WELL ABAND NMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Q <br /> REPLACEMENT❑ <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 E OF WELL <br /> ❑ IN STRIAL �/CXPABLE TOOL Dia. of Well Excavation,42 <br /> (� <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Y <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <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 Joaquin County f <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 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 per s subject to workman's compensation laws of California." ` <br /> I will c r rOspectio F. I to gr utingkand a final inspectio r <br /> i <br /> Signed X Title: - Date: / <br /> (draw an on Reverse Side) <br /> F R DEPA TMENT USE ONLY <br /> PHASE <br /> Application Accepted By �''"�" 4 Date <br /> Additional Comments: <br /> P �Gmnspection ha e Ili final Inspection 'r7Inspection ByDate Inspection By � ''l [Yate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By Janvary 31 0/iuly 1 &Received By July 31 ' <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED R <br /> AMOUNT <br /> FEE <br /> LESS / <br /> PRORATION {` <br /> PLUS <br /> PENALTY J <br /> OTHER ! <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 66Q11 HAZF.6 AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />