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-- Applications Will Be Processed When Submitted ProperlyCompleted. Becure iosign iriesappu—tow ; <br /> ,cE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br />.{Y (COMPLETE IN TRIPLICATE) WATER.QUALIYY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theworkherein ^e,: bed_Thisapplication is <br /> made in compliance with San Joaquin County Ordina ce No. 1862 and the rule and regulations of the San Joaquin Local Health District.,1117 <br /> 1 <br /> Exact Site Address r f City/Town <br /> } 3. <br /> ` Fr Phone ` x <br /> Owner's Name - <br /> Address City <br /> Contractor's Name cense 4 x Business Phone 7 7 <br /> Contractor's Address Emergency Phone f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ "` 1 <br /> WELL CHLORINATION 13WELL ABANDONMENT 13OTHER 13PUMP 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 /> t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> 11DOMESTIC/PRIVATE C1DRILLED 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 />`tt ❑ DISPOSAL ❑ OTHER Other Information <br /> t © GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H:P. <br /> PUMP REPLACEMENT: Stale Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 /> iHomeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit. <br /> is-issued-l-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.followiing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws-of-Califor.nia.'',__ <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> 1 Q " eee r -- Dater – <br /> Signed X _ Title: <br /> � " • � <br /> (t raw.Plot Plan:on Reverse Side) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> kr <br /> Application Accepted By CT Date <br /> Additional Comments: <br /> Phase Il Grout Inspection se I11 Fi inspection Date <br /> Inspection By Date Inspection By <br /> f <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received REMIT <br /> ` <br /> BASE EXPLANATION BILLING 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 6y Date - - Receipt No . _ Permit No; ... ,-`*r Issuance Date Mailed Delivered <br /> ` .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMINSERVICES"`"'•`, 1601 E.HAZELTON�AVE.,P.O Box 2009 --STOCKTON,CA 9 201 m z' <br />