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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) g �WATER QUALITY j 3 .- [q0,---07 <br /> Application is hereby madeto the San Joaquin Local Health District fora permitW construct and/or install the work herein described.This application is <br /> made in compliance with San_Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa oval He th Di trict. <br /> Exact Site Address OWAd d Tr' � - City/Town <br /> 4=? Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name License# LM �9.IBusiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil ith SJLHD? Yes No 1. <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -`A <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.❑ OTHER ❑ PUMP INSTALLATION 0` PUMP REPAIRR <br /> REPLACEMENT❑ 1W I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I <br /> Sewage Disposal Field = Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> P1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 5 Other Information <br /> ❑ GEOPHYSICAL ' Surface Seal Installed By: OP <br /> PUMP INSTALLATION: Contracto <br /> Type of Pump M.P. C> <br /> State Work Dane PUMP REPLACEMENT: <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> w . Describe Material and Procedure <br /> a <br />!i 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 /> 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe t In p r to outing and sinal inspection. <br /> Signed itle, Date: <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> j PHASE Iajilo, ] - Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection ! se Ili Fin Inspection <br /> Inspection By. <br /> Date # Inspection Date <br /> f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received ey January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> I LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY' t <br /> OTHER r <br /> OTHER <br /> Received by Date Receipt,No.' - Permit No - Is 'nce ate Mailed Delivered <br /> p APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 3 <br />