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Applications Will Be Processed When Submitted Properly Completed, Besure Iosign rneHppnca"wn. <br /> LFOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) 4 <br /> •s" „# ENVIRONMENTAL HEALTH PERMIT <br /> PUMP&WELL <br /> MPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ord186nance nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address d_ City/Town <br /> Owner's Name �� Phone ` <br /> Address City <br /> Contractor's Name S License# / — Y Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes__ _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR i <br /> REPLACEMENT❑ (3 <br /> DISTANCE TO NEAREST: Septic Tank Sewer LinesPit Privy 4 <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDE=D USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 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 Seall Installed By: <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done. Iv <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 /> Horne owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> j 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 III call for a Grout.lns do pri tog utio4kand final inspection. p� <br /> l Signed X, file: Date: " <br /> k (Draw Plo Ian on Reverse Side) <br /> i4 FOR DEPARTMENT USE ONLY <br /> PHASE I �' 1�_—W <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection Date <br /> Inspection 8y,�� Date p ection B Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ived By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> i. EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> e DATE DATE REMITTED F AMOUNT <br /> �^- FEE J <br /> LESS <br /> -' Y- PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> FF OTHER <br /> . q-0 <br /> F <br /> Received by Date Receipt No. Permit No. issuanceDate Mailed - Delivered <br /> a - <br /> APPLICANT—RETURN ALL COPIES TO:•. ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />