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4- i <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> !I (For Non-Transferable, Revocable;Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application isIL <br /> r <br /> made in compliance with S Joaquin(°unty Ordinance No. 1862 and the rules and regulations of the S, oaquin Local Health District. <br /> Exact Site Addy ess ., !� fE� � City/Town <br /> Owner's Name Phone <br /> Addressa6 5-` City <br /> Contractor's Name r� License ? Busine <br /> •w ss Phone. — t <br /> Contractor's Address I ' r0_ Emergency Phone <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 CHLOR IINATION 13WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION 6 �PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TOIINEAREST: Septic Tank Sewer Lines Pit Privy <br /> BSewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑J IN �TRIAL- ❑ CABLE TOOL Dia. of Well Excavation <br /> � H <br /> �DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC%PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL!' ❑ OTHER Other Information <br /> 11GEOPHYSIAL 6. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor` �.. ; <br /> I Type of Pump'— <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done G, <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit l <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> a , <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> perrrtit is issued, I shall employ persons subject'to workman's compensation laws of California." <br /> I a Grout Inrec ion prior to grouting and a final Inspection. <br /> SignedTitle: Date: <br /> AF (Draw Plot Plan on Reverse Side) <br /> II <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date Q" <br /> Addition11 <br /> Comments: <br /> Phase H Grout Inspection ha l anal Ins Ion <br /> Inspection By Date Inspection By. Date ? l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> ii BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS n _� <br /> PRORATION I <br /> PLUS <br /> PENALTY! <br /> OTHER <br /> OTHER - <br /> Received iby -Date Receipt No. Permit No. I Issuancti Dat6 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PA,Box 2009 STOCKTON,CA 95201 <br /> i <br />