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Applications Will Be Processed When Submitted Properly Completed. BeSure 10sign 1neHpp"Laiwn. <br /> F R OFFi�E USE: - APPLICATION <br /> "", (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT '� } <br /> (COMPLETE NTRIPLICATE) Oxx�"HTER QOALI�Y_ ar " <br /> Application is hereby made to the San Joaqui��calealth�istnctfora ermittoc lsfuctand/or install the work hereindescribed.This application is <br /> made in comp". nce with an Joaquin C my Ordinance No. 1$62 and the rules and regulati�the�tSan Jo quin Local Health District. <br /> Exact Site Address � '-' os;�'� � <br /> Owner's Name /� nt:�!Phone <br /> Address 2 e7epI City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic TankSewer Lines Pit Privy <br /> �Field6 Sewage Disposa !* 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 /> aDOMESTIC/PRIVATE 13DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION �,f GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ,tel ROTARY Type of Grout t \ <br /> ❑ DISPOSAL ❑ OTHER Other Information G L <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Cl- <br /> DESTRUCTION <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 /> Home owner or licensed agent's signature certifies the following:°I certify that in the performance of the work for which this permit 14� <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 tollowing:"I certify that in the performance of the work forwhich this 5 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Insp tion prior to grouting and a final Inspection. <br /> Signed X Title: Date: <br /> (DrawVolPlan on Revd s Side) c <br /> 0 <br /> 6 FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted 8y Ilero`"''"'� Date <br /> Additional Comments: <br /> ,. has II Grout Inspection / �7 Ph se III Final Inspection V <br /> Inspection By w Date Iy� F -�J 3 -- inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM$T <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE J7J 31 <br /> p <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Cir— �P3—113 1 <br /> Received by Date y Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />