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Applications Will Be Processed When Submitted Properly Completed.Besure Iosign 1nes%PP11e0L1W11. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> '57--.WATER QUALITY � <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework 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 /> �,( � o N (719/4/0 <br /> Exact Site Address City/Town <br /> Owner's Name ! 4 /Y Phone <br /> AM ko LSA City <br /> Address _ <br /> Contractor's Name License# L" Business Phone <br /> Contractor's Address . - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes -- No <br /> TYPE OF WORE( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION t DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION PUMP REPAIR <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 <br /> ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth � <br /> Describe Material and Procedure r� <br /> I hereby certify that I have prepared this application and that the work wili 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 for a Gut In ectionrior to routing and a final inspecti -�— _ <br /> P g <br /> Signed X —= Titre: . Date: <br /> (Draw Plol Plan on Reverse Side) <br /> FOR DEPAR MENT USE ONLY y <br /> PHASE ] Dat0= �J <br /> Application Accepted By � <br /> Additional Comments: <br /> Phase 11 Grout Inspection se III final Inspection _�� <br /> Inspection By Date Inspection By I Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received ByJuly 31 <br /> REMIT <br /> BASE EXPLANATION WI-LING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ?. <br /> Received by Date Receipt No, Permit No. Issuance 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 />