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donsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. — *, <br /> FOR OFFICE USE:-- '''• APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) , <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> 2d <br /> made in compliance with San Joaquin County Ordinance No. l the rules and regulations of the San J+ quin Local Health District. <br /> Exact Site Address I^ City/Town _ ��1�G <br /> Owner's Name 4dC! Phone <br /> Address C r City <br /> Contractor's Name License# 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 WORK (CHECK): NEW WELL❑ DEEPEN 1:1 RECONDITION ElDESTRUCTION❑ <br /> dal <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 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done {1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appro imate Depth rGd <br /> Describe Material and Procedure e <br /> /, <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 forwhich 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 /> i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit i issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will II for a Grout I ectio rior to grouting and.a final inspection. <br /> Signed X - Title: CJCA &G,0V_ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPART ENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date !? 7 ¢ <br /> Additional Comments: <br /> Phase II Grout Inspection Phase IU Final inspection <br /> Inspection By Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ' <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE GATE REMITTED AMOUNT DUE CHECKED 1 <br /> AMOUNT <br /> FEE V } <br /> LESS I <br /> i <br /> PRORATION 1 <br /> PLUS l <br /> ti PENALTY <br /> OTHER <br /> 4 <br /> OTHER <br /> 91%7r 7y !/I71-7cr. i <br /> Received by Date .-- Receipt No. ..,..—Permit No. - Issuance Date Mailed Delivered -� <br /> APPLICANT—RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 t� <br />