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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / <br /> FOR OFFICE USE; APPLICATION <br /> (For Non-Transferable, Revocable,Suspiendable) PUMP&WELL <br /> °- ENVIRONMENTAL HEALTH 46MIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ip <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permitto nstructa, /or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rul s and reg at ons of the San Joej%uin L9cal Health District. <br /> Exact Site Address 1�k City/Town <br /> Owner's Name / �. Phone <br /> Address f �� Y City <br /> Contractor's Name License Business Phone �za L <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .I� .I No P <br /> TYPE OF WORK (CHECK): NEW WELL®DEEPEN ❑ RECONDITION❑ f DESTRUCTION❑ p <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ l <br /> DISTANCE TO NEAREST: Septic.Tank d4 Sewer Lines Pit Privy <br /> Sewage Disposal Field AfZ? Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation- <br /> ❑ DOME=STIC/PRIVATE ❑ DRILLED Dia. of Well.Casing <br /> PI OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing q <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sealf <br /> 13CATHODIC PROTECTION NerARY Type of Grout L i <br /> ❑ DISPOSAL 11 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal In alled By: <br /> PUMP INSTALLATION: Contractor i) <br /> Type of Pump it H.P._ I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe M•aterjal and Procedure I� <br /> I hereby certify that I have prepared this application and $iaf'the work will t e done in accordance.with San Joaquin County i <br /> ordinances, state laws, and rules antic 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 <br /> 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 will caJ14or a Grout Inspection prior to groutina and a final inspection. q / <br /> J. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> Application Accepted By r Date <br /> Additional Comments: <br /> ha it Gr ut Ins a Ion Phas III Final Inspection / <br /> Inspection By Date Inspection By "� a9e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Sanua' 1 8&Received By January 31 © July 1 &Received By Jury 31 <br /> BILLING REMITTANCEi $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O it <br /> FEE ` <br /> LESS �I <br /> PRORATIONPLUS <br /> IIII <br /> 11 <br /> PENALTY Y <br /> OTHER <br /> OTHER <br /> .. Illi <br /> / / <br /> Received by Date - - Receipt No. Permit No. price Date Mailed Delivered .¢ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SER011 <br /> VICES 1601 E.HAZELTON AVE.,P.O.Box 29 STOCKTON,CA 95281 <br />