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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE-USE: , APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Joa�juin County inance No-. and the r d regulations of the SanL,�'a�q+u�ip Local Health District. <br /> Exact Site Address Jl_ a A'i✓ _[l� F �� City/Town e A'j�® M' <br /> Owner's Name Phone <br /> Address _. Cityy11 <br /> Contractor's NarE <br /> 'se Business Phone_ <br /> Contractor's Address mergency Phone ��— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 21-'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /n 0 �774^ Sewer Lines Pit Privy <br /> Sewage Disposal Field 4a Cesspool/Seepage Pit ��-c Other <br /> Property Line� Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <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 Ji ROTARY Type of Grout . 4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By' C <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 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:"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 em to rsons subject to workman's compensation laws of California." <br /> will call for a Gr 1 I p ti pri to grouting and a final inspection. <br /> si t ( Mn al n . 2 c <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) -~-`T� <br /> F ZDEPRTMENT U E ONLY <br /> PHASEI <br /> Application Accepted By t'� Date7 r�Q <br /> Additional Comments: <br /> Phase 11 Grout inspection arse III Final Inspection <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT EX PER SITE ❑ EACH ❑ January 1 & ceived 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 (� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />