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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE` APPLICATIONe <br /> !. (For Non-Transferable, Revocable, Suspendable) r <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is 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 San Joaquin Local Health District, <br /> Exact Site Address 0th3 3 LJ r / - City/Town _ <br /> Owner's Name <br /> ~ © Phone 3 FZ Z oz <br /> + <br /> Address &&kILioonse CityContractor's Name v #t�� Business PhoneContractor's Address/ mergency Phone <br /> Is Certificate of Workman's Compensation Insuranc 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 REPAIR❑ <br /> REPLACEMENT❑ I <br /> + <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ��C/L7�'� Pit Privy <br /> Sewage Disposal Field r r 1421 1 Cesspool/Seepage Pit Other <br /> ' property Line SL� Private Domestic Well A--0-4, Public Domestic Well r. <br /> ` INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> EP50MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .l <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorV l.J <br /> Type of Pump H.P. LtJ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich'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 />` Contractors 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 prior to grouting and a final inspe ' n. <br /> Title: F Date: -� <br /> Signed X # <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 11 <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph e III Final inspection <br /> Inspection By Date Inspection By ,pate <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT 11 PER SITE El EACH ❑ January 1 &Received By Ja uary 1 El July 1 &Received By July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> j DATE DATE REMITTED AMOUNT <br /> FEE <br /> 4 „L4s <br /> I <br /> LESS, <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER r <br /> r <br /> + Received by Date Receipt No. Permit No Issuance Date Ma0ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />