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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFIPE USE: APPLICATION <br /> r'. <br /> - (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) Z-6 3-L S. yy, },� QUALITY <br /> Application is hereby made totheSanJoaqui Local Health District for p rmittoconstructand/or install the work herein described.This application is <br /> made in compliantith S Joaquin County Ordinance No. 1862 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site AddressCity/Town <br /> Owner's Name yD' - " r Phone <br /> Address City <br /> Contractor's Name V, �� License# Business Phone y <br /> Contractor's Address " Emergency Phone I <br /> - I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? 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 /> 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 /> n <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 13 IRRIGATION �7 GRAVEL PACK Depth of Grout Seal •���� <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout r <br /> ❑ DISPOSAL ❑ OTHER Other Information ` <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ILA <br /> PUMP REPLACEMENT: ❑ State Work Done Q <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure �f1� <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 /> F <br /> Home owner 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 employ persons subject to workman's compensation laws of California." <br /> I w v f r a ro n action prior to grouting and a final inspection. <br /> Signed X Title: Date: 2-4 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY .� <br /> PHASE 1 157— f r <br /> Application Accepted By Date <br /> Additional Comments: - i <br /> Phas II Grout Inspection {` 't.i Phase III Final inspection 1 y� <br /> Inspection By Data Inspection By Date <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 /> + <br /> BASE EXPLANATIQN BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER :T - <br /> OTHER <br /> Received by Date Receipt No.- Permit No, I suance Date Mailed Delivered h <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX-2009 STOCKTON,CA 95201 <br />