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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application P' ,hereby made to the San Joaquin Local Health District fora permit to 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 SariJoaquin Local Health District. <br /> Exact Site Address -Za City/Town <br /> Owner's Name 'D < Phone <br /> Address City r <br /> Contractor's Name Q �f License#&_1�.7 3 Business Phone g <br /> Contractor's Address �� c� �� � Emergency Phone _(,_G - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes -- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,.�/ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI� <br /> REPLACEMENT❑ J <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL w <br /> ❑ ❑ CABLE TOOL Dia. of Well Excavation <br /> bOME�IVA ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHr=R Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor LTJ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 0 <br /> Describe Material and Procedure - Q <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. CA <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 caVor a Grout I ection prior to gro Ing and a final inspection. <br /> Signed X Title: Date: I <br /> (Draw Plot Plan on Revees Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B,_7j7,6 Date <br /> a Additional Comments: <br /> Phase II Gro It ectionha�11al inspection <br /> Inspection By ate Inspection By Date - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 4 ❑ July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE 5 <br /> LESS <br /> PRORATION �" ~ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -9")— <br /> Received <br /> Received by Date Receipt ND. Permit No- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />