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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <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 the rules and regulations of the San Joaquin Local Health District; <br /> Exact Site Address vo, City/Town _�.5 � <br /> Owner's Name Phone <br /> Address ev City_.. - <br /> Contractor's Name a License#�/ �Business Phone �1 - T <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi Yes NO - n <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 _ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL-CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRM <br /> REPLACEMENT❑ ;; p <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy J <br /> Sewage Disposal Field Cestpool/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 , k•.❑' GRAVEL PACK-- Depth of Grout Seal a <br /> ❑ CATHODIC PROTECTION -El'ROTARY- Type of Grout <br /> ❑ DISPOSAL 11-OTHER t Other Information <br /> ❑ GEOPHYSICAL } Surface Seal Installed B :. <br /> PUMP INSTALLATION: Contractor e <br /> Type of Pump H.P. 1O <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: Well Diameter IF 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 /> Home owner or licensed agent's signature certifies the following"I certify that in theberformance 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 fvrwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />' 1 fill call for a Grout Inspe do p r g�rou�tg and final inspection. v <br /> Signed itle: — r Date: <br /> x', (Draw Plot an on Reverse Side) ' <br /> h <br /> (FOR DEPARTMENT USE ONLY ) ^7 <br /> PHASE ,1,1- - �tAe_ Date �A-b��p� <br /> Application Accepted By fin• "^"`T� <br /> Additional Comments: <br /> Phase 11 Grout Inspection PhaselUl Fin-all Inspection f <br /> Inspection By / <br /> Date Inspection By � "" Date / <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE 1EXPLANATI1.114 BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 5 <br /> FEE ' <br /> I LESS <br /> PRORATION ! <br /> PLUS <br /> PENALTY c - <br /> OTHER R ! <br /> a <br /> OTHER <br /> Received by Date Receipt No PerNo- <br /> L Is uance ate Mailed Delivered <br /> mit <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />