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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applic tion <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pL1MP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wl h San Joaquin County 9rdinanc No. 1862 and the rules a d regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town _-7,' -e— _ <br /> Owner's Name �. _ Phone <br /> Address City <br /> Contractor's Name License# isiness Phone '� t <br /> Contractor's Addressk <br /> ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,,N EI - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER El PUMP INSTALLATION I��UMP REPAIR❑ <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 Weil <br /> INTENDED USE TYPE OF WELL f <br /> ❑, IN��RIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Casing l <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surf Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <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 /> 1 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 sha11 employ persons subject to workman's compensation laws of California." <br /> a I �Grout�Insecfi prior to grouting and a final inspection. <br /> Signed X Title: �+ A Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY !� <br /> PHASE �r- <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection se III ,final tnspectiopoo <br /> Inspection By Date Inspection Bye G Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Il PER SITE ❑ EACH; ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 T <br /> REMIT 1!i <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS 7 tiJ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER h <br /> Received by Date Receipt No. Permit Nv. Issbancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />