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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) iV0'e_77­(t:J06 e05 A-,/F—WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance 0 h an Joaquin Chunty Ordinance No, 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (t City/Town <br /> Owner's Name n 4t,rA Phone <br /> Address City <br /> Contractor's Name License #3—sam Business Phone <br /> Contractor's Address loi 9a0 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❑ DESTRUCTIONCI <br /> WELL CHLORINATION ❑ WELL ABANDONMENK OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy o f <br /> Sewage Disposal Field Cesspooi/Seepage Pit Other ai <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation O <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing h <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 /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter AIRproximat 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. <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 h' ' or sub-contracting s! nature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is is I shall employ subject to workman's compensation laws of California." r <br /> I willL: a Grout Ins I for t routing and a final ins e <br /> Title: Date: <br /> (Draw Plot Plan ide) <br /> FOR DEPARTMENT USE ONLY ell <br /> PHASE ! J <br /> Application Accepted By Date '20 �/ <br /> Additional Comments: <br /> hase 11 Grout InspectionPhase III Final Inspectio <br /> Inspection By � � <br /> Date� Inspection By Date <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 /> BASEEXPLANATION KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 4 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rr^l <br /> Received 6 Receipt No Permit No. Issua ce Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />