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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 '. <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work"herein described.This application is <br /> made incompliance vilh San qu" Couniy Ordinance No 862 and a rules and regulations of the San uin Loca Health District. <br /> Exact Site Address it City/Town [v <br /> Owner's Name rS Phone <br /> Address �" City <br /> Contractor's Name License# Vus1 ens Phone <br /> Contractor's Address a Emergency Phone a — , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No N <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ cx�} <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ e <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 Excavatio n <br /> DOMESTIC/PRIVATE ' ❑ DRILLED Dia. of Well Casing ? �r <br />_ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout c?LST P a <br /> ❑ DISPOSAL OTHER Other information �A� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ^IMG-.� Q. 11 G �� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done_ 6 - eA7 (� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: t 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. k <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance ofthe 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 /> 9 � <br /> I w' II for a Grout Insp on Vprioo grouts and a final inspection. f <br /> Signed X Title:. - _ ____ .Date: <br /> (Draw Plot Plan on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY s <br /> PHASE <br /> Application Accepted By " Date <br /> x <br /> Additional Comments: <br /> P se 11 Grout Inspection ase IIIFinalIInns ection <br /> Inspection B kCL v 1 D e �-- t. Inspection fay ' Date 7 <br /> �0 <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 /> BILLING - REMITTANCES• $ <br /> ' BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED- AMOUNT <br /> Q� <br /> FEE <br /> LESS y <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> U <br /> Received by Date Receipt No, Permit No. ssuanc Date - Mailed Delivered' - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />