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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <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 made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> i <br /> made in compliance with San Joaquin County Ordinance No. 1 62 and the rules and regulations of the San JoaqL aJ Health District. II <br /> Exact Site Address ��rJ City/Town � � - 1 <br /> I <br /> r <br /> Owner's Name ! Phone <br /> Address City r <br /> Contractor's Name �. <br /> License �-7'J--�rBusiness Phone � J <br /> ✓ d Em r encYPhoneContractor's Address <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes�. No <br /> TYPE OF WORT( (CHECK): NEW WELL 13 DEEPEN C1RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRJ3 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 ❑ CABLE 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 al Installed B -, <br /> PUMP INSTALLATION; Contractor Id *---^� <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: Wel! Diameter Appro ' ate Depth r � X_ <br /> Describe Material and Procedure_ {/1 <br /> dd <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 /> 1. <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 all for a Grout Inspection t ro ing d a i a1 inspection. <br /> 1;4 <br /> Signed X _ Date: l Q �� <br /> (Draw Plot n on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> r 4 - Date <br /> Additional Comments: <br /> Phase II Grout Inspection a III Fi on <br /> r <br /> Inspection By Date Inspection <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH nary 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 /> s Q 0 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 11 <br /> Received by Date Receipt No Permit No. I Issua ce Dile Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />