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Applications Will Be Processed When Submitted ProperlyCompleted. Be SureTosign TneAppncarlon <br /> 7FOR oFF; E USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) pt]MP&WELL <br /> v� ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 j <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> U r t/ 1!Ijr City/Town <br /> Exact Site Address - <br /> Owner's Name Phone <br /> Address City <br /> r <br /> Contractor's Name License# _t.._ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> I., <br /> TYPE OF WORK (CHECK): NEW WELLj❑ DEEPEN 11 RECONDITION 13DESTRUCTIO,N�❑� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER 11 PUMP INSTALLATION 1 PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy w <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property LWe Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> ❑ IN RIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> E DOMESTIC/PRIVATE 0 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 Installed By: <br /> 1` <br /> PUMP INSTALLATION: Contractor <br /> $Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 r1'ta for a Grout In pection prior to grouting and a final inspection. <br /> Sign <br /> Title: _— t►".� Date: <br /> !! <br /> (Draw Plot Pian on Reverse Side) i <br /> (� FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> Application Accepted By Date <br /> Additional Comments: <br /> `!! Phase Il Grout Inspection PhVse III Fina_JJpspection <br /> Inspection By Date Inspection By Date <br /> 111 r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary 1 &Received 13y January 31 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1 i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> j OTHER <br /> C- <br /> Received by Date Receipt No. Permit No. - 155ua ce Date Mailed Delivered ..+r <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HA2@ETON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br />