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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable,'Rbvocable Suspendable) PLUMP&WELL. <br />" ENVIRONMENTAL:HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE _W gTER QUALITY r (]c Z <br /> i Application is hereby made to the San Joaquin Local HealthDistriEtfopermittoconstructand/or install the work erelndescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1,8&2 and the}rules and regulations of the San Jo uin ?cal Health District. <br /> Exact Site Address tt ` City/Town �S-_ 4r <br /> Owner's Name Phone <br /> Address i a 2 City <br /> Contractor's Nam ` License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑" DEEP N ❑ RECONDITION❑ DESTRUCTtOant <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST- eptic 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 /> r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> RUMP REPLACEMENT- ❑ State Work Done l <br /> PU REPAIR: ❑ State Work Done <br /> RUCTIO - L: Well Diameter Ap ro imate epth \� <br /> Describe Material an Procedure w r <br /> up <br /> j I hereby certify that I have prepared this application an hat 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 /> I 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 i Lied, I shall employ persons subject to workman's compensation laws of California." <br /> I will I r a r 1 Inspection prior to grouting and a final inspection. <br /> Signed X Title: — Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE! <br /> Application Accepted <br /> Additional Comments: <br /> a hil Grout Inspection �. h s III Final Inspection 2 <br /> Inspection Byko� Date / Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ P SITE ❑ EACH -❑ January 1 R Received By January 31 ❑ July 1 R Received By July 31 ' <br /> REMIT <br /> BASE EXPLANATION BILLING, REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> FEE D O <br /> I LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k Received by D e Receipt No. Permit No. Issuance 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 />