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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOROFFICE USE: APPLICATION <br /> /SQ (For Non-Transferable, Revocable, Suspendable) '� PUMP&WELL <br /> 7l- ENVIRONMENTAL HEALTH PERMIT 3 <br /> (COMPLETE IN 3-RIPLICATE) V 7Y51 51 ;J>_, FZ)ro' MATER 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 applicatio-n is <br /> made in compliance with San Joaq Co nt Ordin nce No. .862 qmdthe rules and gul,tion ofn Joaquin Local j-lealt Dist ict. <br /> Exact Site Address y/TQ^ <br /> Owner's-Name Q� _• ' Phone ; <br /> 90 <br /> Address , . ., .. City" <br /> Contractor's Name License# Q�i Business Pho <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE O <br /> WELL CHLORINATION NEW <br /> ABANDONMENT 11 OTHER PUMP <br /> ❑ <br /> P INSTALLAT ON ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 0 Sewer Lines Pit Privy <br /> Sewage Disposal Field 100 1 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well 4i <br /> INTENDED USE T TYPE OF WELL r/ <br /> ❑ INDUSTRIAL - © CABLE TOOL Dia..of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing q� <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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor O <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ state Work Done V` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 /> 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 /> I wil call for a Grout Ins tion prior to grouting and a final inspecti n. <br /> Signed X Title <br /> Date: <br /> (Draw to Plan on Reve se Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> P eset Inspection �j Phase ill Final Inspection <br /> Inspection By. Date �a� ! Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S.Received By July 31 <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY <br /> --OTHER <br /> OTHER <br /> Y/�� <br /> Received by llf Dat !lIJJJ fJ Receipt No, ,. .e))rrnA No. <br /> lllLJy A Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />