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Applic t I f i�c ell W& b fitted Properly Completed. Be SureToSign TneAppucaTion. <br /> FOR OFFICE USE: PLICATION <br /> (F -Transferable, Revocable, Suspendable) <br /> AUG 7 '��k�r' PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) SAN JOAQUIN LOCAL WATER QUALITY <br /> Application is hereby made to the SarHEALuTUc9[U1RksrXrictfor a permitto construct and/or install the work herein described.This application is <br /> made in compliance wi h San Joaquin Count Ordinance No.1862 and the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address I nT_a Gil ,/ City/Town _ <br /> Owner's Name ; Phone Address6 <br /> t / City <br /> Contractor's Name License# --� Business Phone_ , s - <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes 1 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0 <br /> WELL CHLORINATI N ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13PUMP REPAIR❑ y <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 /> ❑ 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 s <br />- ❑ DISPOSAL 13 OTHER Other Information <br /> ..1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> T'pe of Pump . L.� <br /> PUMP REPLACEMENT: In State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> W <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County-A <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 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 for which this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. V <br /> Signed X Title: Date: O <br /> (Draw Plot Plan on Reverse Side) <br /> F DEP TMENT SE ONLY <br /> PHASE I J <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ha 1 inal Inspection pp�� <br /> Inspection By Date 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 /> ASE EXPLANATIO BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BATE DATE REMITTED AMOUNT ` <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> Received by Date Receipt ND. Permit o- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />