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ApplicationsWillBeProcessed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FQR aF: ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance))with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaqum cal Health District. <br /> Exact Site Address_f- City/Town <br /> Owner's Name I /Q / Phone L7 '2 ' <br /> Address it ri * 04.- City <br /> Contractor's Name License # 7g�,L Business Phone <br /> �— <br /> C <br /> Is Certificate of Workman's Compensation Insurance <br /> Contractor's Address mergency Phone n File With SJLHQ? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ CID <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION (1t PUMP 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 Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ' ❑ CABLE TOOL Dia. of Well Excavation <br /> 03-60MESTIC/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 p Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor Gr E] ;-- A; <br /> Type of Pump e� <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:"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 will call for a Grout Insp cion prior to gr uting and a final inspecti. . <br /> Signed X Title: <br /> Dat <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE.I . <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ili Final Inspection <br /> Inspection By Date Inspection By f� 0Y� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �a v <br /> LESS ff�� <br /> PRORATION h(y40 <br /> PLUSQaV, �W _ <br /> PENALTY ,�/// �/ / ( / r l <br /> OTHER a� /"v .S�IdH O[ d C•.! ll LJ LLfU�- I'LV 6e t�,�.(O y ` <br /> OTHE <br /> l `'} '�c <br /> Received by —FDt No. Permit No. �. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES--wp— 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �- <br />