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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.OFFICE-USE: APPLICATION f' <br /> (For Non-Transferable,'Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) (p22 W►�pTER QUALITY <br /> V ,, _ ., . w f.3 Of0j),03S <br /> fi <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 wh San Joa Ui Co my Ordinanc o. 1862 and the rules a,d gulations-of the San ijaWuin Local Health District, <br /> Exact Site Address City/Town T <br /> Owner's'Name "" Phone. <br /> Address City. " > <br /> Contractor's Name '` w.. License# 7� Businessor'te' } <br /> Contractor's Address r t _� 4' s ?Emergency Phone 11 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes _-_ No. <br /> TYPE OF WORK (CHECK): NEW WELL O DEEPEN ❑ RECONDITION❑_- DESTRUCTION <br /> 11 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER 13 PUMP INSTALLATION PUMP REPAIR 13 <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 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 ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL Surface Seai Installed By: <br /> PUMP INSTALLATION: Contractor - 4 N' <br /> Type of Pump H.P. r <br /> Ni <br /> PUMP REPLACEMENT: ❑ State Work Doe ° <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth " <br /> Describe Material and Procedure <br /> h <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I w II call for a Groutspection prior to grouting and a final inspec n. <br /> I Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection h J fnal Inspection <br /> .Inspection By Date Inspection By Date <br /> ti <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 /> BILLING- REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE L 6 , <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. Permit No. Is uance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />