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Properly <br /> Applications Will Be Processed When SuAPPI�Cp►T��Np e 1 <br /> FOR OFFICE USE: <br /> (For Nan-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health Districtfora permittoconstruct and/or install the work herein described.This application Is <br /> Application is hereby made tothe San Joaquin <br /> n Joa n County Ordinance No 862 and the les and regulations the San Jp�quin tical Hgraith District. <br /> made in compliance with S Ci <br /> Exact Site Address '"� �� � �? <br /> A/V 13 a Phone <br /> Owner's Name City <br /> Address ��'�Business Phone_ <br /> License#� j <br /> Contractor's Name - <br /> Contractor's Address > Emergency Phone L <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> � <br /> TYPE OF WORK (CHECK): WELL/ABANDONMENT ❑ELL 0 DEEPEN ❑ OTHER E O❑DITIOP❑P IN D AL ATIION*W PUMP REPAIR❑ <br /> ESTRUCTIONO <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Pit Privy <br /> Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 DRILLED Dia. of Well Casing <br /> E] DOMESTIC/PRIVATE Gauge of Casing <br /> i ❑ DOMESTIC/PUBLIC 13 DRIVEN Depth of Grout Seal <br /> [I IRRIGATION <br /> 11 GRAVEL PACK <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1 <br /> 11 DISPOSAL <br /> [1 OTHER Other Information <br /> � Surface Seat Installed By: <br /> ❑ GEOPHYSICAL �J} <br /> PUMP INSTALLATION: Contractor Y <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done �I <br /> I Well Diameter Approximate Depth ��6 <br /> DESTRUCTION OF WELL: ' <br /> Describe Material and Procedure <br /> Vil- <br /> 1 herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> G <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 d <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I certifies the following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f I will call f a rout Inspection prior grou ' g <br /> and a final inspection. <br /> �r Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I ��� d f? Date <br /> Application Accepted By <br /> Additional Comments: PZha I l Final Inspection <br /> Phase it Grout Inspection Date <br /> Inspection By <br /> Date Inspection By <br /> IPER UNIT ❑ PER S4TE ❑ EACH C1 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> TIQN BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> i Received by Date CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES <br /> 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, <br />