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Applications Will Be'Processed When Subrill'Properly Completed. Se Sure To SignTheApplication. <br /> FOR OFFICE USE: t i� APPYCATION <br /> 161;114l (For Non-Transferable, Revocable,Suipendable) t <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WI=LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the!San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ord nce N 1862 an the ruleraand regulations of the San Joaquin Local Health District. <br /> Exact Site Address SCor,�� City/ o n <br /> .I i w.� <br /> Owner's Name ✓ Phone <br /> Address c 'r a - City <br /> t Contractor's Name - i License#193 7. Business Phone <br /> Contractor's Address r Emergency Phone <br /> Is Certificate of Workman's Cotaipensation Insurance on Fie With SJLHD? Yes_. _� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT El 11I <br /> I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field - —Cesspool/Seepage Pit Other <br /> Plroperty Line Private Domestic'Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> �❑ir,t INDUSTRIAL ❑ CABLE.TOOL Dia. of Well Excavation <br /> I�1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i <br /> ❑ DOMESTIC/PUBLIC I ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I I ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal nstalled By: <br /> PUMP INSTALLATION: Contractor e. <br /> Type of Pump— 6A H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP f4f3fiilim: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 rlemploy 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I ; <br /> I wil call for a Grout Inspection prior o r utfrig a a f nal inspection. <, ' <br /> ., <br /> Signed ie: Date: <br /> i� (Dr w Plot P In on Reverse Side) <br /> FO DEP RTMENT SE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection 1 <br /> I' Inspection By Date Inspection By ate <br /> 1 ;1 If <br /> Fee IS Due: ❑ ANNUALLYI, ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ©-tlJuly 1 8 Received By July 31 <br /> REMST <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUN DUE ' CHECKED <br /> .I DATE DATE REMITTED ' AMOUNT <br /> IFEE .• � "�- ' .� - - _ __ _ <br /> LESS d <br /> PRORATION <br /> PLUS 1� <br /> PENALTY ,f <br /> F �IOTHER <br /> OTHER III' <br /> Received by` ., Date Receipt No. Permit No. Issuance D to Mailed Delivered <br /> APPLICANT 'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />