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Applications Will Be ProcessedWhenSulim'itted Prf'';**" :.ompleted. Be Sure To Sign The Application. <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I <br /> Application is hereby made tc 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 Joaquin Local Health District. <br /> Exact Site Address Ad City/Town MmAke <br /> Owner's Name Phone _+^ �, � <br /> Address City�Q__. __ P ,.ry I'0 <br /> Contractor's Name License#2 Business Phone —� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran4e on File With SJLHO? Yes No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M— PUMP REPAIR J <br /> REPLACEMENT❑ `! <br /> t ( , <br /> DISTANCE TO NEAREST: Septic Tank �.� _ Sewer Lines 7 57 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 ABLE TOOL Dia. of Well Excavation <br /> ®'DOMESTIC/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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor PAilvef 5!Al /P,, - <br /> Type of Pump U H. . <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 Ins ection prior to routing and a final inspecillon. <br /> SignedjX Title: + Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY a <br /> PHASE <br /> Application Accept&y ,�, <br /> Additional Comme <br /> Pha�e/I rrout Inspection r has -II Fi al Inspection _ I <br /> Inspection By / v/ Date Inspection By 7 = Date <br /> r. <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31. <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS j <br /> PENALTY <br /> OTHER <br /> OTHER - — <br /> &9k <br /> Received 6y Date - Receipt No. " Permit No. t Issua ce Date Mailed Delivered f <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 Ei HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />