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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1 <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 /> made in compliance with San Joaquin C unty Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone </ - <br /> ' <br /> Address City. <br /> Contractor's Name License#/4 Business Phone <br /> Contractor's Address / r `Emergency Phone 9 � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ti <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN'❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑-' N V <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> ti+ <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 F <br /> ❑_DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well'Casing w <br /> 13DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing j <br /> _13—IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal } <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> i ❑ DISPOSAL c ❑ OTHER Other Information <br /> ❑ GEGPHYSICAL--- + =i- -- -- - urface-Seal Installed By: g <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. 1 "_52— <br /> PUMP <br /> PUMP REPLACEMENT: ElState Work Done, <br /> PUMP REPAIR: ❑ State Work Done` '7 <br /> DESTRUCTION OF WELL: '".Well Diameter � � 4 �^ Approximate Depth '1 <br /> t {� f <br /> ,--" �`Descrlbe.Material.and Procedure S <br /> I hereby certify that I have prepared this appiication.a d'tliat 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 /> 'Homezwner or,licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> rs issued,:.)`shall.riot employ.any.person in,such_manner_as to.become subject to workman's compensation laws ot.Califomia." <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." i <br /> I wit all for a Grout In ection prior grouting and a final inspection. + <br /> Signed X IAF -Title: sr Date: <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE ! - r <br /> Application Accepted By ��� ' `'' Date <br /> Additional Comments: { <br /> Phase II Gro t I ection r s II Final Inspection <br /> Inspection By. ate Inspection By Date <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 DVF CHECKED <br /> AMOUNT F <br /> FEE <br /> LESS Y <br /> PRORATION Y <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER 4. <br /> � Q <br /> Received by Date Receipt No. Permit No. I uan a Date J� Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />