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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appficattan. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit toconstruct 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.Joaquin al Health District. <br /> Exact Site Address 4 + (/" , �� .� City/Town CVo Lo <br /> Owner's Name �" ~.', v '�' Phone " <br /> Address City f ' <br /> Contractor's Name License Nusiness Phone <br /> Contractor's AddresS1 �t`�s �� C;`�'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): -NEW WELL� EPEN ❑ RECONDITION❑ DESTRUCTION❑?„' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ d <br /> REPLACEMENTEIDISTANCE TO NEAREST: Septic Tank ZZ:� 0`Te'Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 60 Private Domestic Well Public domestic Well <br /> INTENDED USE TYPE OF WELL �f <br /> 2_�ODSTR <br /> IAL 11CABLE TOOL Dia. of Well Excavation <br /> MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 49 J <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 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 /> y Approximate Depth <br /> ' Describe Material and Procedure = <br /> I hereby certify that I have prepared this.application and that theywork 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'sSignature certifies the following:"I certify that in the performance of the work forwhich 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 shall employ persons subject to workman's compensation laws of California." _ <br /> I wil�fora Grout Inspection prior to gro1 and a final Inspection. <br /> Signed X _ Title: <br /> _. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE e <br /> Application Accepte y e Date <br /> Additional Comme s _ <br /> hale t Inspection c ase Final Inspection <br /> Inspection BDateInspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE,. 11 EACH ❑ January 1'&Received By January31 ❑ July 1 &Received By Jufy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE -DATE REMITTED AMOUNT <br /> FEE tl ' <br /> LESS <br /> PRORATION <br /> 'PLUS <br /> PENALTY <br /> OTHER <br /> /D Z <br /> OTHER � ( <br /> Received by ` ate Receipt No - - milt N Is uange Date. Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />