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.It AppocauonsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County,0 d'n 1862 a d the rulos and regulations of the San Joaquin Local Health District. <br /> Exact Site Address {IIJ/Jr, �/�( City/Town <br /> i <br /> Owner's Name J <br /> Address Phone — O <br /> City v <br /> Contractor's Name License Business Business Phone 'f <br /> Contractor's AddressQ( -_ — ''�old — <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank f�Cj -� Pit Privy <br /> p Sewer Lines <br /> Sewage Disposal Field f Cesspool/Seepage Pit Other ^ <br /> Property Line/D f f Private Domestic Well 51 Public Domestic Well i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOLq <br /> Dia. at 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 /> El GEOPHYSICAL Surface Seal Installed By: 1. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done H,P. <br /> PUMP REPAIR: ❑ State Work Done \r <br /> DESTRUCTION OF WELL: Well Diameter Approximate depth <br /> Describe Material and Procedure <br /> r) <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 /> 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 /> Iw' for a Gro inspect' p ' to g and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Revers ide) <br /> PHASE ! FOR D PARTMEN USE ONLY <br /> Application Accepted By DateCiy A_A <br /> Additional Comments: <br /> ,Ph se II Grout Inspection Pha a III Fina nspection <br /> Inspection By Date <br /> Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH ❑ January 1 &Received B Januar <br /> Y Y 31 El July 1 &Received By Juiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE (.! AMOUNT <br /> LESS / L� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - p <br /> Received by Date Receipt No. M00�Permit No. Issuance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201' <br />