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Applications Will Be Processed WhenSubmitted Properly Completed. BeSureTosignTneAppncatlon. <br /> FOR OFFICE USE: APPLICATION <br /> C4 yd4jQ (For Non-Transierable, Revocable, Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Joaquin County Ordinance No. 1862 and t rul and regulations of the San Joaquin al Health District. <br /> Exact Site Address City/Town <br /> Owner's Name f 1`7 *, Phone <br /> Address � �City <br /> Contractor's Name License# l ,�� Business Phone Y ~' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes m k No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® ,� <br /> REPLACEMENT❑ t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ <br /> e <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well �1 <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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Install' <br /> �. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ifs, <br /> PUMP REPLACEMENT: ❑ State Work Done 9 <br /> PUMP REPAIR: 00 State Work Done di Z db <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that-t 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 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, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection p t r ting a ' al in .tion. <br /> Signed X e: Date: V7 lee <br /> (Draw Plot in on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date �n V <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final I ection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE El EACH ❑ January 1�FF ived By rnuary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCEREMIT <br /> BASE EXPLANATION DATE DATE MITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> JFF <br /> FEE <br /> LESS vl 3 J f <br /> PRORATION <br /> PLUS I / <br /> PENALTY <br /> OTHER <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.Boa 2009 STOCKTON,CA 952D1 <br />