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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' ~– <br /> FOR 1,3FFICE USE: <br /> ,APPLICATIONIlk <br /> r i (For Norwr094 ble, Revocable, Suspendable) <br /> ' ENVIRONMENTAL HEALTH PERMIT PUMP&WELL _. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is, <br /> made in compliance w.11 I;pith San Joaquin County Ordinance No. 18 2 and the ules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address 3 j � � o zyee�, <br /> City/Town <br />� Owner's Name j <br /> Address Phone <br />� Contractor's Name City� License <br /> Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes– '< No <br /> TYPE OF WORK (CHECK): NEW WELL . DEEPEN El RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: <br /> Septic Tank r CA <br /> p Sewer Lines Pit Privy <br /> i Sewage Disposal Fit Id Cesspool/S epage Pit -� <br /> Other y <br /> Property Line _6 Private Domestic Well.. � Public Domestic Well ""'�"' <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL �► 4 <br /> ❑ CABLE TOOL Dia, of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVENJ/ <br /> Casing i" <br /> Gauge of ,� ��� <br /> ❑ IRRIGATION A GRAVEL PACK Depth of Grout Seal r <br /> _ ❑_CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information b <br /> El GEOPHYSICAL � kX <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTiON OF WELL: Well Diameter <br /> Approximate Depth <br /> = Describe Material and Procedure <br /> —1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C unty <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 1 <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 r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' call for a ro In sp f' n prior to grouting and a final inspection, f <br /> r <br /> Signed X y <br /> Title: Date: <br /> (Draw Plot Pfan on Reverse Si ) I <br /> i <br /> OR DEPA T ENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: <br /> Date 77 11 <br /> P ell Grout Inspection <br /> Inspection By Date r �`/Ph Final In ection <br /> Inspection Bye/" rte" Date _F--J 75' <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 S <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> # <br /> Received by Date � �` <br /> Receipt No. Permit N E suan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - ;.1 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95.201 �bj <br />