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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> USE: APPLICATION <br /> FOR OFFICE <br /> /S 14444 (For Non-Transferabie,Revocable,Suspendable) PUMP&WELL <br /> I� ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) _ * <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> •is <br /> made in compliance with San Joaquin County O durance No. 1862 ara6ls and regulations of the San Joaquin Lq64 Health District. <br /> Exact Site Address f City/Town <br /> Owner's Name . Phone <br /> Address ✓r City - <br /> Contractor's Name " License# ` Business Phone —V' I <br /> Contractor's Address �• +� 'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW.WELL'❑- DEEPEN 0 RECONDITION❑ --DESTRUCTION❑ - U <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® <br /> REPLACEMENT❑ 14 <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 v t 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.:f Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> II PUMP INSTALLATION: Contractor <br /> ' Type of Pump 11 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: �I State Work Done f " <br /> DESTRUCTION OF WELL: --I Well Diameter Approximate Depth -' <br /> jDescribe Material and Procedure * - <br /> ' i <br /> ' I hereby certify that I have pPepared this application and that the work will be done in accordance with San Joaquin County 4 <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 performanceof thework 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.", <br /> j I will a!1 for a Grout Irispection prior gr utipg' d a inspects <br /> Signed XES) e Date: 7> <br /> (Draw Plot Pla Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �f <br /> .Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection F P e Ill Fin n <br /> Inspection By Date .Inspection <br /> Fee Is Due: ❑ ANNUALLY ❑ PLR-UNIT" ❑ PER S1TE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> ' PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuante Dafe Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 91111 <br />