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Applicafions Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> G (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY o- <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 in County O in No. 1862 the_rqJes and regulations of the San oaquin Local Health District. <br /> Exact Site AddressCity/Town r <br /> Owner's Name 6y ^ <br /> Phone o� <br /> Address a " City C) <br /> Contractor's Name License#�/0 Businessghone <br /> AV <br /> a <br /> Contractor's Address 4& 99 Emergency P o e <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yesr —- <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAID ; <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 p GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Q <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: f State Work Done ,rf �. <br /> 1 <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 /> t <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 subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> .r <br /> Signed X L <br /> Title:, Date: _7, <br /> (Draw Plot Plan on Reverse Side) .� <br /> J <br /> .FOR DEPARTMENT USE ONLY <br /> PHASEf <br /> Application Accepted By -�+G��c� �—�E�' Date Za— <br /> Additional Comments: <br /> Phase II Grout Inspectionh se Ili Final spection <br /> Inspection By Date Inspection By ate <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> tt BILLING REMITTANCE - $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> f 'Z1 <br /> FEE .� <br /> LESS <br /> PRORATION I <br /> 1 i <br /> PLUS <br /> I <br /> PENALTY t <br /> OTHER <br /> gb 4 "OTHER <br /> �Aryl <br /> Received by Date !Receipt No. Permit No. Is uanc .Date Mailed Delivered r jJ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _.3 <br />