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{r" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _,!t; .oR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> r Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstructand/or install thework herein described,This application is <br /> made in compliance wi S a in Dunt Ordi n N 86 and the rules and regulations of the San Jo in Local Health District. <br /> Exact Site Address A City/Town <br /> Owner's Name AP Phone <br /> Address City <br /> Contractor's Name License# 8 siness bone <br /> s '" f <br /> Contractor's Address Emergency Phone _�� "" <br /> r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 10,1( No <br /> I <br /> t TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN <br /> ' WELL CHLORINATION 13 WELL ABANDONMENT El OTHER C1 PUMP INSTALLATION+=u PUMP REPAIF <br /> i REPLACEMENT❑ <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> j DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> j DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> j ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I, PUMP INSTALLATION: Contractor S <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i PUMP REPAIR: X State Work Done <br /> 1 DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 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 /> will call for aGro Inspection rior to grouting and a final inspe 'on. <br /> f Signed X Title: Date:,4:�p <br /> (Draw Plot Plan oneverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� � � ��� <br /> Application Accepted By, .-.._ Date <br /> Additional Comments: <br /> Phase II rout Inspection III Final peciion <br /> Inspection By Date Inspection B� a�k]ate //—/2 �-.rGt <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE J1wY <br /> LESS 141, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s ff <br /> Received by Date Receipt No = Permit No. Issdance bate Mailed Delivered <br /> r APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95207 <br />