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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR"OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co un y Or mance No. 1862 and the rules and regulations of the San Joaquiq Local Health District. <br /> Exact Site Address 11 City/Town <br /> Owner's Name Phone <br /> City <br /> Address � / ' 6ff- 3.3 tl3 <br />� Contractor's Name ense Business Phone <br /> t Contractor's Address 0 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHL ION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMEN <br /> 4 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 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL — Surfgce Seal lnstalle y: <br /> PUMP INSTALLATION: Contractor9 A <br />( Type of Pump H.P. s -� <br /> PUMP REPLACEMENT: El State Work bone <br /> L 4-41(4- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that.l 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 laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 will call for a Grout Inspect! n prior 10 grouting and a final inspection. <br /> Signed X <br /> Title: Date: Q d <br /> (Draw Plat Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> Application Accepted By c ?� Date" <br /> Additional Comments: <br /> Phase If Grout Inspection ctio <br /> is Inspection By Date Inspection By ate <br /> kr Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> i LESS <br /> PRORATION <br /> { PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER <br /> I. JV1—Z sZ3 . <br /> E CJ. '7/7/ 0 (a-2_3 0'(4315 717/ 0 <br /> Received by Dale Receipt No. Permit No Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTtlN,CA 95201 <br />