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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I� APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I� 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 C unty Ordinanc�o 862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address�//Y! s� � City/Town <br /> Owner's Name Phone <br /> Address iso? City -- <br /> Contractor's Name 7"A � License# Business Phone <br /> Contractor's Address D Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WA SJLHD 2 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> a <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 <br /> ❑ <br /> INDUSTRIAL . ❑ CABLE TOOL' - Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED 'Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> ' PUMP INSTALLATION: Contractor Cv <br /> Type of Pump — H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> r <br /> DESTRUCTION OF WELL: it Welt.Diameter Approximate Depth <br /> I Describe Material and Procedure -- <br /> .I <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 orsub-contracting signature certifies the following:,"I_certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons sublect to workman's compensation laws of California.°' - " } <br /> c <br /> I <br /> 1011 call for Grout In ec' rio to gro ting an�a final insp -lion. <br /> �- Signed Title: _ Date! a- A <br /> (Draw PI Plan on Reverse Side) <br /> I� FOR DEPARTMENT USE ONLY <br /> PHASEI T <br /> I Application Accepted By '� �` (� Date <br /> Additional Comments: i! <br /> Phase II Grout Inspection Phase III Fi al Ins ction ' <br /> Inspection By Date Inspection By to <br /> d <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> IIREMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> ,i AMOUNT <br /> ! FEE Vr T — <br /> LESS I1'1 <br /> PRORATIONPLUS <br /> PENALTY I� # <br /> OTHER I! <br /> I ! - <br /> OTHER <br /> ii <br /> !i d a3 <br /> k Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ��;vs <br />