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S_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (Far Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with an Joa uin ounty Ordinance No.1862 and the r♦u{ s a d regulations of the San Joaquin Local Health District. <br /> Exact Site Address ��j✓' �l� L� < �� . City/Town <br /> Owner's Name L ;9� <br /> Phone ____ -1 <br /> Address Cit W <br /> Contractor's Name LicenseJ ness Phone e . <br /> Contractor's Address ] �l Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4' No <br /> TYPE OF WORK (CHECK): NEW WELL R;---DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /�/J� - Sewer Lines Pit Privy <br /> Sewage Disposal Field �50_ �4Eesspool/Seepage Pit Other <br /> s' <br /> Property Line / Q Private Domestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Wei I Excavation j <br /> ,,.,,,,���� <br /> L�DOMESTIC/PRIVATE <br /> 11 DRILLED Dia. of Wei I Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f� <br /> ❑ IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> r�� <br /> ❑ CATHODIC PROTECTION �R r ARY Type of Grout r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <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 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 /> 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 ill 1 rout Inspection prior to grou nd a final inspection. p x <br /> Signed X - Title: Date: I/ Z <br /> I r1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> I <br /> Application Accepted Date <br /> Additional Comments. <br /> Phase Ii Grout Inspection pQrnll f Wtf-r -f P se ' FinaJfrispection —k�3 <br /> Inspection By Date Inspection By - L% Date 7 z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING R REMIT <br /> MITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION � O <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> [. U <br /> Received by D to I Receipt No. Permit No. IssWance 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 />