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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> i (For Non-Transferable, Revocable,Suspendable) <br /> w PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaqui Local Health District. <br /> Exact Site Address City/Towr6.11 4111071%_? <br /> Owner's Name V fill Phone <br /> Address City <br /> Contractor's Name i v License#,W Business Phone _ <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Ins ur nce on Fife With SJLHD? Yes L____ No <br /> !TYPE OF WORK (CHECK): NEW WELL E] DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ rl <br /> .DISTANCE TO NEAREST: Septic Tank ` s/ Sewer Lines 2,e5 A Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line' lln': Private Domestic Well - d 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 0 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL It Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump : e-- r-- X,� P. <br /> PUMP REPLACEMENT: ❑ State Work Done F <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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." e <br /> i <br /> I will call for a Grout In ectionlprior to grouting and a-final inspection. <br /> 1 <br /> Signed-XV,I.., <br /> _. Title_ _ &I Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accept By '^ Date 1 <br /> Additional Comm ts: <br /> 4 <br /> Phase It Grout Inspection If Final Inspection q <br /> Inspection By Date Inspection B <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3t ❑ July 1 &Received By July 31 F <br /> BILLING REMITTANCE $ ' . REMIT <br /> _ BASE EXPLANAT40N AMOUNT PATE GATE REMITTED - DUE CHECKED <br /> AMOUNT i <br /> FEE ; <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY } <br /> OTHER r # <br /> OTHER <br /> fleceiUed by Dale Receipt No -Permit N.. Issua ce Date Mailed Delivered xr <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 # <br /> t.F - , <br />