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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Fp OFFICE USE: �. APPLICATION <br /> –� (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Joaqgtn Count Ordinance No. 1862 and the rules and regulations of the San J�oJ n Loc H a� Ith District. <br /> Exact Site Address I� City/-T"wrrJ �G <br /> of <br /> Owner's Name 1el <br /> Phone <br /> Address City <br /> Contractor's Name License <br /> Business Phone <br /> Contractor's Address IM Emergency Phone <br /> Is Certificate of Workman's Co kpensation Insura e on File With SJLHD? Yes Lam' No <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ a <br /> E REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ ! Sewer Lines �C�[1 <br /> „i — Pit Privy C <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r� <br /> Property Line_ZAI� Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> r 9 <br /> ❑ IN,.ISTRIAL % m❑ CCABLE TOOL Dia. of Well Excavation <br /> E$DOMESTIC/PRIVATE CHILLED Dia. of Well Casing / U/,L <br /> ❑ DOMESTIC/PUBLIC ` I ❑ DRIVEN Gauge of Casing S" <br /> ❑ IRRIGATION ❑� GRAVEL PACK Depth of Grout Seal <br /> 13 , <br /> f <br /> CATHODIC PROTECTION ; R'OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SuVace a nsta ed 8y: <br /> PUMP INSTALLATION: I Contractor <br /> Type of PumpH.p <br /> PUMP REPLACEMENT: i ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> .Ii! <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 hiringofisub-contractin signature certifies the following:i ,` 9 g g:"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 all fo��r)r�e ction prior to grouting and a final inspection. <br /> Signed XCD , Title: r"" Date: 7 <br /> Ili (Draw Plot Plan on Revers Side) <br /> Ili FOR PARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> I� <br /> Additional Comments. <br /> Phase 11 Grout Inspection P Phase I11 Final Inspection <br /> r Inspection By it Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY .�� ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> IIIBILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> Ij DATE DATE REMITTED AMOUNT- <br /> FEE <br /> w <br /> LESS <br /> PRORATION <br /> PLUS I . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT— ALL COP <br /> -- IES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />