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ry Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppllcaiton. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Appl icatian is hereby made to the San Joaquin Local Health Di permitto construct and/or install the work herein described.This application is f <br /> made in compliance with Sawn Joaquin CoLot Ordi nce N . 62 and the rules and regulations of the San aquin Local Health District <br /> Exact Site Address-31A9. Phon own <br /> Phone <br /> Owner's Name <br /> City <br /> Address ® <br /> Contractor's Name License# //� _.� Business Phone <br /> Contractor's Address Emergency Phone <br /> f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP WSTALLATION;i�, PUMP REPAIR❑ <br /> Ile <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r^ <br /> Property Line Private Domestic Well Public Domestic Well v <br /> I� INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> tU <br /> PUMP INSTALLATION: Contractor 001, " <br /> Type of Pump P. Q <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 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:1 certify that in the performance of the work for which this permit o <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.' O <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work farwhich this <br /> n <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c I r a Grout Inspec 'on prior to grouting and a final inspection. 41 - <br /> Signed X <br /> Title: Date: (� <br /> (Draw Piot <br /> an on Reverse Side) <br /> 1 <br /> i F R DEP RTMENT U ONLY G <br /> PHASE IDate/J r� -m—e Q <br /> o/ <br /> Application Accepted By__;z Z 2- <br /> Additional Comments: <br /> P as 11 Groui Inspection Phase 111 'nal Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece y January 31 ❑ July 1 S ReceiveRd By July 31 <br /> BASE ExPLRNATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> j DATE DATE REMITTED AMOUNT <br /> FEE LA <br /> LESS <br /> PRORATION <br /> i PLUS <br /> PENALTY <br /> OTHER <br /> OTHER .. <br /> L Received by <br /> Date Receipt No. Permit No. / Issuance Date Mailed Delivered <br /> I 7601 E.HAZEL70N AVE.,P.O.Box 2005 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11 - <br />