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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO_ROFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) i <br /> n PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San JoaquinLocal-Health Districtforapermit toconstruct and/or install the work"herein described.This application is <br /> made in compliance with San Joaquin ounty Ordinaqce No. 862 and the rules and regulations of the San Joaquin ocal Health District: <br /> Exact Site Address �° City/Town G fl / <br /> Owner's Name r [. Phone <br /> Addressity <br /> Contractor's Name License Business Phone �' 1 <br /> Contractor's Address Emergency Phone C <br /> Is Certificate of Workman's Compensation.lnsurance on File With SJLHD? Yes No r <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN © RECONDITION❑ DESTRUCTION❑ ; <br /> WELL CHLORINATION ❑ WELL AB NDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ } <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ e_0_0'� Pit Privy ,t <br /> Sewage Disposal Field Geoeptral/Seepage Pit Z Other <br /> Property Line ) nvate Domestic Well " Public Domestic Well <br /> INTENDED USE TYPE OF WELL pr `1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> tDOMESTIC/PRIVATE Dia. of Well Casing <br /> D <br /> DOMESTIC/PUBLIC DRIVEN Gauge of Casing 21 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION" �ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ Surface Seal I stat ed By: <br /> PUMP INSTALLATION: Contractor y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: ❑ State Work Done <br />' DESTRUCTION OF WELL: Well Diameter 'Approximate Depth f <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of lhework 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 /> l - <br /> I I fo I lion prior to grouting and a final inspection. <br />•. Signed X JF Z tie: Date: <br /> (Draw Plot Plan on ReverseAide) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ['�� ,,b 1�� <br /> Application Accepted By ` + �-�"`'" _ Date i <br /> Additional Comments: I <br /> P ase Grout Ins ectlon2 6 Ph se Ill Final Inspection <br /> 1� � <br /> Inspection By t Date 7__.X16 Inspection By Datgl <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janua/zlr ❑l July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING r REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION - <br /> PLUS - _.,. - .. –. .. 1 <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> 6: Received by Date Receipt No Permit No IssuafnceDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 ..,.,, <br />