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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> OFFICE USE: APPLICATION 0 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto constructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance N . 11862 and the rules and regulations of the Sa aquin Local Health District. <br /> Exact SiteAddress City/Town. <br /> Owner's Name Phone 93 <br /> Address City e <br /> Contractor's Nam L )t�lcense Business Phone — O <br /> Contractor's Addres F'4tmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes !___� No <br /> TYPE OF WORK (CHECK): NEW WELL 2f_� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 14—PUMP REPAIR❑ <br /> REPLACEMENT❑ ( d' <br /> DISTANCE TO NEAREST: Septic Tank _. 5__�Q �� ewer Lines Pit Privy �✓ �` <br /> Sewage Disposal Field Cesspool/Se epage Pit �/ -� Other <br /> Property Line — Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,�,., INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> Y -1:yOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout <br /> ❑ CATHODIC PROTECTION e OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump <br /> H.P. <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t� <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-contr ting signature certifies the following:1 certify that in the performance of the work for which this <br /> permit is issued, I shall a loy pe ons subject to workman's compensation laws of California." <br /> ill call for a Grout Insp tl n rio to grouting and a final inspection. <br /> I <br /> Signed X Title: tin ( L'�� Date: <br /> r (Draw Pot Plan on Reverse Side} <br /> 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted By Date <br /> Additional Comments: <br /> a e II Grout Inspection 14 P se III Final)nspection <br /> Inspection By Date 2 Inspection B Date /Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -r <br /> LESS <br /> PRORATION F <br /> PLUS '-d <br /> PENALTY <br /> OTHER <br /> OTHER <br /> =a7�) y <br /> Received by hate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />