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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> to Me (For Nan-Transferable,`Revocable,Suspendable) PUMP&WELL <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> (COM LETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto 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 N . 1862 and ules d regulations of the San Joaquin Local Health District. <br /> Exact Site Address 0 A ., I City/Town <br /> Owner's Name r 40 Phone`' <br /> Address 4`� )- City <br /> Contractor's Nam A.r ' <br /> " License#;/T '7 Business Phone `"7! w <br /> Contractor's Address -Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK)' NEW WELL❑`^'--DEEPEN ❑ RECONDITION❑: DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ rr1 <br /> REPLACEMENT❑ <br /> I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 1 Cesspool/Seepage Pit Other <br /> + Property Line Private Domestic Weil Public Domestic.Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN k Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 1 ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump S H.P. / <br /> PUMP REPLACEMENT: State Work Done �e,�L�riG/ <br /> R State Work Done -� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth "4) <br /> Describe Material and Procedure - -- -. <br /> d <br /> 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 agenes 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 Inspe dor o gro ng and_ final inspection. - <br /> Signed X. _ �itle:. a Date: <br /> # (Draw Plot Ian on Reverse Side) ' <br /> - FOR DEPARTMENT USE ONLY ` <br /> PHASE-1 Jt <br /> Application,Accepted By rt p.— I I Date r <br /> Additional Comments:' <br /> Phase II Grout Inspection Phas IIIA Final-I`nJspection <br /> Inspection By Date Inspection Bye (-! ^� Date - <br /> Fee IS Due: ❑ ANNUALLY PER UNIT '❑ PER SITE '❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received 8y July 31 <br /> r $- REMIT <br /> RASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE a s� <br /> LESS, o _ <br /> PRORATION <br /> PLUS ;. <br /> I <br /> PENALTY - t <br /> OTHER <br /> OTHER <br /> Received by Date. Receipt No. Permi o. Iss ante-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 />