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} Applications Will Be Processed When Submitted Properly,Completed. Be Sure To Sign The Application. <br /> -FOR Of.FICE,USE: <br /> APPLICATION <br /> ` 'Ail _. (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I, <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 6ittoconstructand/or install the work.herein described.This application is r <br />} <br /> made in compliance with San Joaq in ounty O dinan .No. 18 n he rules and regulations of the San Joaquin�Local Health District. <br /> Exact Site Address City/Town ` <br /> �� A" <br /> Owner's Name piod Phone �! <br /> Address _ City �a ®� .o - <br /> Contractor's Name ,. License# Bu ess Pho1e ' <br /> r - , <br /> Contractor's Address Emergency Phone <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ h' { <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR,J <br /> REPLACEMENT❑ <br /> IDISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> kProperty Line Private Domestic Well Public Domestic Well <br /> I INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED �+ Dia. of Well Casing <br /> r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Q GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. TM <br /> PUMP REPLACEMENT: ❑ State Work Done T <br /> I PUMP REPAIR: State Work Done :i <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 I <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance,'of the work forwhich this r <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> I will call for a Grout 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 /> PHASEI <br /> P <br /> �,_ - Date <br /> Application Accepted By �� <br /> f Additional Comments: <br /> Phase II Grout Inspection h el inal Inspection 1 <br /> Inspection By Date Inspection By Date �f ��(`• <br /> f f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 , <br /> BILLING REMITTANCE $ REMIT <br /> j BASE EXPLANATION AMOUNT DUE CHECKED , <br /> t DATE DATE REMITTED AMOUNT <br /> FEE_ 1 <br /> LESS_ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> s <br /> OTHER a <br /> t <br /> OTHER <br /> Received by Date Receipt No. -Peuenit No. I uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 9520 <br />