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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppucauon. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Swspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 1N TRIPLICATE) WATER QUALITY <br /> Application is IN <br /> herRI madelotheSanJoaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance w'th an oa in Cou ty Ordinance No. 1862 and the rules and regulations of the San o in Loc I Health District. <br /> Exact Site Address r City/Town �/ <br /> Phone <br /> Owner's N � , <br /> City G <br /> Address _ y <br /> Contractor's Name License © B� in ss <br /> Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation l sprance on File With SJLHD? Yes No s� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONS j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Linej�2 Private Domestic Well Public Domestic Well f <br /> INTENDED USE TYPE OF WELL <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 — l <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P._ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ^ _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth b <br /> Describe Mat ' I and Procedure <br /> i <br /> I hereby certify that I have prepared this applidan 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi c II for a GG .out Inspecti n p 'or to grouting and a final inspection. <br /> Signed X Title: Date: <br /> ` (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI ' (�, ,� _ <br /> C�l pate <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase I11 Final Inspection <br /> , Inspection By <br /> Date Inspection By Date <br /> I ; i <br /> [ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El.PER SITE El EACH ❑ January 1 &Received By January 31 C1 , 1 &Received July 31 <br /> _ REMIT - <br /> F BILLING REMITTANCE $ AMOUNT DUE CHECKED — <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> t FELESS <br /> E r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> OTHER <br /> I�� 3 <br /> t r. <br /> Received by Date Receipt No Permit No. Issu nce Date Ma0ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Bax 2009 STOCKTON,CA 9 <br />