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a g Applications Will Be Processed When Submitted Properly Completed.Be SureToSign IneAppilcOLIVI-- <br /> FOR-OFFICiE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal l the work,herein described.This application Is <br /> made in compliance with San Joaquin C my Ordinance No. 1862 and the rules and regulati City/TownSan uin Health District. <br /> Exact Site Address i <br /> Phone <br /> Owner's Name ` City <br /> Address License usiness Phone <br /> Q � <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Co pensation Insurance on File With SJLHD? Yes - <br /> TYPE OF WORK (CHECK):- NEW WELL❑DODEEPEN NMENT ❑❑ OTHER 11 ITIOP❑P IN TALLATION 13 PRUCTIONO UMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABA <br /> REPLACEMENT❑ v Pit Privy <br /> Sewer Lines y <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <br /> j ❑ INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing 2 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> El GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Descgbe Material a�td Pio ure <br /> I hereby certify that I have prepared thl application <br /> t and that theJoaquin work <br /> will <br /> bedone D'lsin trica cordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations ofhe San <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance m 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 will call for a Grout Inspection pri to grouting and a final inspection. R <br /> 1 Pc� Title. _ Datgr <br /> Signed X ' <br /> raw Plot Plan on Rev Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phase II Ina Inspection <br /> Phase It Grout Inspection Date <br /> C <br /> Inspection By � Date inspection 13y <br /> ❑ ❑ R SITE EACH -❑ January 1 &Received By January 31 ❑ July i &ReceivREMITBy uly 37 <br /> Fee 15 Due' ANNUALLY PER UNIT El PE <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DAT REMITTED AMOUNT <br /> FEE �� F <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —// v ; - -- O • Mailed Delivered <br /> / Permit No, Issuance-Date <br /> P.O.Box 2009 STOCKTON,CA 95201 <br /> Received by to + Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE., <br />