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Applications.Will Be Pro ssed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: Ij APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> F <br /> WATER QUALITY �. � i X-1i D##s' :in-;n <br /> (COMPLETE IN TRIPLICATE) v v. .- :1. <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaq Fin County Ordinance No. 1862 and the rules and regulati <br /> ons-of the San Joaquin Local Health District. " <br /> � arra� C <br /> Exact Site Address �e? Lti� rot City/TownIF <br /> JJ <br /> e?Tiit'Yr �� �• r Phone_City' . <br /> Owner's Name � <br /> Address _ " � , <br /> Contractor's Name � �� License#!�� Business Phone'`' <br /> Contractor's Address Emergency Phone' <br /> 10 <br /> Is Certificate of Workman's Compensation Insurance on File W h SJLHD? Yeses No f[ <br /> WORK (CHECK): NEIN WELL❑ n DEEPEN ❑ RECONDITION u DESTRUCTION❑�� -� T f <br /> TYPE OF W ( ) it <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION a PUMP REPAIR <br /> REPLACEMENT[] fb <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines , Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 11 <br /> 4 Property Line Private Domestic Well � Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ' <br /> El CABLE TOOL Dia. of Well Excavation - <br /> ® DOMESTIC/PRIVATE. 13DRILLED Dia. of Well Casing <br /> I © DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I ❑ ROTARY Type oft Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Insta ed By: <br /> PUMP INSTALLATION: # Contractor <br /> 4 Type of Pump H.P. <br /> PUMP REPLACEMENT: I• ❑ State Work Done <br /> pump IWX 1Z State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 have-prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state lawE Pand rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licenseld agent's signature certifies the following:A 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 shah employ persons subject to workman's compensation laws of California." <br /> t <br /> I w!I a 1 for Gr t� c'to o r uting ,nd a final inspection. <br /> Signed X <br /> itle: Date: <br /> r (Draw PI Plan on Reverse Side) <br /> - <br /> "FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted �I Date <br /> Additional Comments: G ' <br /> Phase N Grout Inspection hase III Final nspection <br /> lnspectian By- h f Date inspection By. Date <br /> yII t i <br /> ' Fee Is Due: C3 ANNUALLY 9� ❑?PER UNIT . [I PER SITE ❑-EACH- " ❑ January T'&Received By January,31 ❑ July &Received By July 31' <br /> REMIT <br /> 4r BILLING -REMITTANCE ,$ AMOUNT DUE CHECKED <br /> BASE "EXPLANATION DATE DATE REMITTED AMOUNT <br /> l� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS" <br /> PENALTY <br /> r <br /> OTHER - e <br /> OTHER <br /> ,-t Received by- - - ^ ---' - _ - - I uance D e Mailed Delivered <br /> Date Receipt No. Permit No. <br /> - <br /> y: J APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br /> 0 <br />