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Applications Will Be Processed When Submitted ProperlyCompleted. Be5uretoSign ine rappncauum <br /> FOR OFFICE USE: I�[� <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable). <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ; <br /> 1 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 Or inance No. 186 and the rules and regulations of the San Joa Local ealth tri�t. <br /> Exact Site Address City/Town � � — <br /> Owner's Name H 1 Phone <br /> Address ew City <br /> F r' ,, ..+ <br /> Contractor's Name b1 L' erase t` Business Phone. <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR� <br /> k REPLACEMENT❑ <br /> Nli <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> AL <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> C Property Line Private Domestic Well Public Domestic Well <br /> M <br /> INTENDED USE TYPE� 11 CABLE TOOL WELL <br /> TOODia. of Well Excavation <br /> 11 INDUSTRIAL <br /> i J&DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br /> G ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` <br /> t ❑ IRRIGATION (] GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑. OTHER Other Information <br /> r ❑ GEOPHYSICAL Surface Seal I stalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 51 State Work Done . <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> 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:1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall emplo persons subject to workman's-compensation laws of California." <br /> Y <br /> I ill call for a Grout Inspe�do p cr gro g and a final inspection. <br /> Signed isle: Date: 4 <br /> C L (Draw Plo an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I i 1 2� <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase If Grout Inspection Phase III Final Inspection <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r FEE <br /> I, LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 71 <br /> Received by - Date r Receipt No. Permit No. Issuance Date Mailed Delivered . ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />