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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EFORRCE use: APPLICATION i(For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install theworkherein described.This applicationis <br /> made in compliance with S n Joa ui Count Ordinance No. 1862 and the ules and regulations of the San Joaquin Local Health Di <br /> alt strict. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address City - <br /> Contractor's Nam Ni 6-Ae#. SS" Business Phone <br /> Contractor's Address E;a�e�e �— 6 13-�� <br /> Is Certificate of Workman's Compensation Insurance ori File With SJLHD? Yes G� No <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines C� Pit Privy <br /> � <br /> Sewage Disposal Fiel¢ r Cesspool/Syeepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well Xr <br /> INTENDED USE TYPE OF WELL f l/ <br /> ❑,_,,,, INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> 0-6-0MESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal d <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 6'GP2/11 �� -� <br />` Type of Pump H.P. <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 /> 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 for which this <br /> permit is issued, I shall em I y ersons subject to workman's compensation laws of California." <br /> i, <br /> will call for a Gr u ti pr or to grouting and a final inspection. <br /> Signed X <br /> Title: CZ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> ® FOR DEPARTMENT USE ONLY <br /> PHA <br /> Application Accepted By �, Date <br /> Additional Comments: - <br /> p rout Inspection Phase RI Final Inspection <br /> Inspection By Date Inspection By Date <br /> t ` <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT :❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedJuly 31 <br /> REMIT <br /> k BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> f rr p O <br /> FEE # j� <br /> LESS <br /> ' PRORATIONIO,�,, ' <br /> t PLUS { <br /> PENALTY <br /> OTHER is <br /> OTHER <br /> �n <br /> p Received by Dale -Receipt No. Permit No. Issuance Date Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON, <br />