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Applications Will Be Processed When-Submitted Properly Completed. Be Sure To Sign The Application. .. <br /> FOR OFFICE USE:' APPLICATION <br /> / <br /> (For.Non-Transferable, Revocable, Suspendable) <br /> S <br /> ENVIRQNMENTAL HEALTH PERMIT PUMP&WELL <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal the work herescribed.Th�application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the n <br /> e6�� 0=� /S/�d I✓ rules and r gulations of the San Joaq n Lo f Health Dis ictF <br /> Exact Site Address ori <br /> City/Town �G <br /> Owner's Name <br /> Phone <br /> Address <br /> City t <br /> Contractor's Name License # <br /> Contractor's Address Business PhoneEmergency Phone f <br /> Is Certificate of Workman's Compensation Insurance on File Wit'' SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION pESTRUCT ON❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT❑ PUMP REPAIR,® <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> . Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> � I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC ❑ Dia. Well Casing <br /> DRIVEN Gauge <br /> of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea] <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout ` <br /> ❑ OTHER Other Information r, <br /> ❑ GEOPHYSICAL Surfacl Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: E'State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <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 /> Home owner 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 taws 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 o workman's compensation laws of California." <br /> I wit call for a Grout Inspection rI r g utin and a ' at inspection. <br /> Signed X le: <br /> Date: <br /> . Draw Plot non Reverse Side) <br /> OR D ARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection .f P 11 Final I ction E <br /> 4 <br /> Inspection By Date Inspection By / + <br /> ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Recewed 8y July 31 <br /> BASE EXPLANATION BELLING REMITTANCE $ REMIT <br /> DATE DATE REMITTEAMOUNT DUE CHECKED <br /> REMITTED AMOUNT <br /> FEE AMOUNT i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Perm}t o. <br /> Iss ance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 ' STOCKTON,CA 95201 <br />