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Applications Will Be Processed When Submitted Properly Completed. tieSure 1oWgn 1"e^FIM•­-. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 0.4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY cation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. p <br /> ibThis apli <br /> made in compliance with San Joaquin Count Ordinanci No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 3�. O City/Town <br /> Owner's Name 14 Phone <br /> Address Y City <br /> Contractor's Name • <br /> *' ,' License#1f�7jkS Business Phone GZ ��� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Q <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Pia. of Well Excavation <br /> 9 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 Sea!l Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump SmA 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 /> 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:"]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 voll call for a Grout iinnsspectio or to gro ling and a final inspection. � <br /> Signed '���r Idle: Date: <br /> i <br /> (Draw Plot rVan on Reverse Side) <br /> , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date3'� <br /> Application Accept By <br /> Additional Comm nts, <br /> Phase It Grout Inspection 4iase III Final s ection <br /> Inspection By Date Inspection By T DateBy J <br /> 2 <br /> Il r Fee Is Due: 13ANNUALLY [3PER UNIT ❑ PER SITE 13EACH ❑ January i &Received By January 31 ❑ July 1 &Receiv REMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> � 56a <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit <br /> rmitt Ngo. � ssua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />