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Applications Will Be Processed When Submitted Properly Completed. Be SureTosignTneAppucauon <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ! <br /> (COMP"TE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application i's <br /> made in compliance with San Joaquin County Ordinance <br /> /No. 862 and the rules and regulation�phe f tan oaquin Local Health Di trict. <br /> Exact Site Address r.'• / t/yl(�° v' <br /> Owner's Name &Mrnq C te, iI�f'1 f' Phone t <br /> Address City /pC �'� — <br /> Contractor's Name License#� Business hone �"l 8 <br /> Contractor's Address 'S�- C Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank 7� Sewer Lines Pit Privy <br /> Sewage Disposal Field 7d/� 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 Excavation / <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing wa�� <br /> i I <br /> ❑ IRRIGATIONS GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ial ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: JU <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump HAP_ _Q <br /> PUMP REPLACEMENT: 0 State Work Done <br /> I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth -/ <br /> Describe Material and Procedure <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i 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 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." 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this 1 <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> 1 will all for a Grout inspection prior to grouting and a final inspection. (� <br /> Signed X l�S' ' " �• Title: . _ Date: 5 <br /> IE (Dra Plot Plan on Reverse Side) <br /> 19 FOR DEPARTMENT USE ONLY f � <br /> PHASE ! � Date <br /> Application Accepted By <br /> Additional Comments: <br /> h se 1 Grout Inspection ha e I Final Inspection <br /> t <br /> Inspection Date Inspection Date <br /> Fee IS Due: NNUALLY (� PER UNIT ❑ PER SITE ❑ EACH ❑ January eceived By January 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUF CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1 FEE <br /> li LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTH£R <br /> 1 ' <br /> OTHER }� <br /> Received y Date , Receipt No. Permit No. Issuance Date Mailed Delivered- <br /> - A APPLICANT—RETURN ALL COPIES TO: k ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20139 STOCKTON,CA 95201 <br />