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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign TheApplication. <br /> �rOR FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k - <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 /> l made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Logy Health District. <br /> Exact Site Address !' City/Town f <br /> V <br /> Owner's Name +! Phone r <br /> AddressCity 7paw g- <br /> Contractor's Name, L_ sed eloa r.�-� License#�- �„�Business Phone <br /> Contractor's Address _ao=%O � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit'7( <br /> S HD? Yes No <br /> i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ i C <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 ❑l ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP RE OM: ®-State Work done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate ❑epth <br /> �- <br /> Describe Material and Procedure - <br /> Lx <br /> fp <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 /> j Home owner or licensed agent's signature certifies the.following:"I certify that in the performance of thework forwhich this permit <br /> i is issued, I shall not er4ioy 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-iollowing:"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 /> 1 1 call for a Grout inspe to ri to gr9utft%qanV,final inspection. -X <br /> Signed Date: <br /> I (Draw Plot Plan on-Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE k�. <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection I Ina spection <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 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY yU <br /> OTHER <br /> OTHER <br /> to <br /> Received by - ' Qate F -: eceipt No. � Permit No. Issuance Da—� Mailed Delivered <br /> R <br /> APPLICANT—RETURN ALL COPIES TO: ENVtRONMENTAL.HEALTH PERMIT/SERVICES 1601 E,'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br />