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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> PQtiOFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT _ PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r <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 /> made in compliance with'San Joaquin Pqqhty Ordin No. 1862 and the rules and regulations of the San.Joa n/Local a Ith District. <br /> Exact Site Address r /lam .. G'�'F'� City/Town <br /> Owner's Name11 PZ Phone <br /> Address City '} <br /> Contractor's Name License# Business Phone r d <br /> ------------------ <br /> Contractor's Address • f a Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran on File With SJLHD? Yes Noi <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 Lined Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation VAV <br /> r• <br /> .&DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SLS face Seal I =11d <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump `� -� H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done — <br /> �:r <br /> DESTRUCTION OF WELL: Well Diameter f Approximate Depth �Jy <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 I <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' or sub-conlracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> Permit is is u ' ' I s II employ persons subject to workman's compensation laws of California." <br /> 1 will call t r a r� ut specti n pri) grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final inspection <br /> Inspection By Date �� inspection By :� 7 ����- -Date 14 l�r <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> BILLING REMITTANCE $ REMIT <br /> ECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOl/NT DUE AMOUNT <br /> FEE 8 <br /> LESS <br /> PRORATION L <br /> PLUS ] <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit'No. I uance bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Box-2009 STOCKTON,CA 95201 <br />