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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICEsE: .. ;, APPLICATION <br /> e - r_6;,V16 <br /> l (For Non-Transierable, Revocable,Suspendable) <br /> "" �! PUMP&WELL � G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 5 <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 Joaquin Co rity inance No. 186 and the rules and regulations of the San JcI a Health District: <br /> Exact Site Address A ' as ds City/Town <br /> Owner's Name Phone <br /> Address S3 <br /> Contractor's Name License# L .3?LJ Business Phone 6-L ?L <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes C No d <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION_ ® PUMP REPAIR❑ <br /> REPLACEMENT❑ r. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic.Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL s~ <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 urface Seal Installe y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Y H.P, <br /> PUMP REPLACEMENT: . -19,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:"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 v#fl call for a Grout InsiI for to routi g and final inspection. 1 <br /> rte"" � <br /> Signed life: Date: <br /> `i <br /> ( raw Plo an on Reverse Side)( 7 <br /> x <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Z <br /> - Date <br /> Additional Comments: <br /> Phase II Grout Inspection h e Il'F <br /> FinaInspection 7 <br /> Inspection By Date Inspection By D te <br /> Fee Is Due: [].ANNUALLY. ❑ PER UNIT 11 PER SITE ❑ EACH ❑ January 1 &Received y anuary 31 LJ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> (�d� <br /> LSJ Y `f�S ,. <br /> LESS <br /> PRORATION <br /> PLUS d <br /> PENALTY <br /> OTHER <br /> e OTHER <br /> i <br /> 613 Tat <br /> I Received by Date Receipt No, Permit No Issuanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CO <br />