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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F(�H`oFFIcFwusE: APPLICATION �(�,_ s2- <br /> (For Non-Transferable, Revocable,Suspendable) ar 1 <br /> ENVIRONMENTAL HEALTH PERMIT L.0&4& PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I <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��� Cou�y Ordinance No. 1862 and the rul � regulations of the Sary,Loaquin Local Health District. <br /> Exact Site Address L City/Town C > <br /> Owner's Name Phone —,?1 � <br /> Address City— <br /> Contractor's <br /> ityContractor's Name <br /> -7iJ- j License#w Business Phone <br /> Contractor's Address �O(X.3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes IA No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <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 S <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout di <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done -f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .Q <br /> Approximate Depth a <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 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 o alifornia." <br /> I will ca11 a ro nspec' n rior to <br /> lipleuting and a final inspect!o ? <br /> Signed X "' 'Title: Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE 1 w. <br /> Application Accepted ByR^ A^ Alp <br /> Date <br /> Additional Comments: y <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection B 0Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> BILLING REMITTANCE $ REMIT 7. <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> DATE <br /> FEE 44 t4 <br /> LESS <br /> PRORATION <br /> } <br /> PLUS w <br /> PENALTY <br /> 1 <br /> OTHER 44 <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date ¢ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 9520 <br />