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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) <br /> PUMP&WELL <br /> l ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 <br /> made in compliance with San Joaqui County Ordinance NQ. 1862 and the rules and.regulations of the San q`in Local Health District. <br /> Exact Site Address City/TownIff- <br /> Owner's NameK-a r _ Phone <br /> Address / City f <br /> Contractor's Name 01 License# Business Phone <br /> Contractor's Address tl Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11DESTRUCTI N❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER 13 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank! l Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Ii <br /> rt Line P <br /> Property rivate Domestic Well Public Domestic Well <br /> O <br /> INTENDED USE I:� TYPE F WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> 4 ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information { <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: 0 State Work Done 'T <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 16A <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 /> ii 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 /> I will II for a Grout Inspectilon prior to-grouting and a final inspection. <br /> Signed X Title: Date: <br /> 3 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I "w <br /> i <br /> Application Accepted By �\ Date Z� <br /> Additional Comments: <br /> Rh s I Grout Inspection P se II Final Inspection <br /> Inspection By Date Inspection By Date <br /> i <br /> i <br /> I` fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By duiy 31 <br /> E BILLING REMITTANCE $ REMIT <br /> Ii BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> j FEE f �LJ <br /> I! LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER <br /> -- <br /> Received by I Datel Receipt No. Permit No. Issuance Date Mailed Delivered r <br /> I�° APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />