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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WDLL <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICWATERUALITYATE} Q <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 withSan Joaquin Gaunt Orclinai No. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 2/ 1� City/Town <br /> Owner's Name r1 Phone <br /> Address City <br /> Contractor's Name License#� Business Ph / 7� 7 <br /> Contractor's Address Emergency Phone 6 2 7 <br /> Is Certificate of Workman's Compensation surance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DEARUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ {,.:'PUMP INSTALLATION ❑ PUMP REPAIR❑ � <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Pr t <br /> Sfl ._- Cesspool%Seepage Pit Other <br /> ewage Disposal Field %f t <br /> Property Line Private Domestic Well ' Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL, Dia. of Well Excavation// f <br /> `91 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing's <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ,j ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ' Surface Seal Installed By: .+ <br /> PUMP INSTALLATION: Contractor `v <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:- ❑ State Work Done O <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure __ 1 <br /> I hereby certify that lihave 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. i <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit n <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 hiringor sub-contracting signature certifies the followir I certify that in the performance of the work for which this <br /> 9 9 9��� Y <br /> permit is issued, I shall employ persons subject to workman's compensation..laws of California."- <br /> i <br /> 1 will call fo -a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> a' FOR DE7RTME7SE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By 'I ifs• f`� 1 <br /> F E -- <br /> Additional Comments: - <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <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 AMOUNT DUE CHECKED <br /> • DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY '. <br /> OTHER <br /> OTHER <br /> �rk bi o �J S-7� <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Ti ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />