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., .,.f.- <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign aApplication. <br /> FOR OFFICE APPLICATION <br /> CQ nyjp��. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> -- JJ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is N TRI LICATmade the San JoaquinLacalHealthDistrictforapermittoconstructand/or install the work.herein described.This application is l <br /> made in compliance with San Joaquin Count Or inance No. 1862 and the ruses and regulations of the San Joaquin Lo al Healt Ditric <br /> Exact Site Address fo /,. City/Town <br /> Owner's Name �'�sa Phone <br /> Address City d t <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes_-; - No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �1 <br /> REPLACEMENTO <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 /> PB'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 "Cl ROTARY Type of Grout <br /> I <br /> ❑ DISPOSAL 0 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Sealled By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump r N.P. , <br /> ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP ❑ State Work Done <br /> I App oximate Depth <br /> DESTRUCTION OF WELL: 'Well Diameter <br /> `Describe Material and Procedure <br /> f <br /> rt; l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> yha 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:1 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." i <br /> I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this j <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 4till call for a Grout Inspection prior gr utin and final inspection. ] <br /> �. -Itle: Date: <br /> Signed ;, <br /> & (Draw Plot an on Reverse Side) <br /> F R DE P RTME USE ONLY <br /> PHASE I7 G C) <br /> Application Accepted By <br /> 7Date <br /> Additional Comments: r <br /> Phase 11 Grout Inspection Phas II nal Inspection � ) <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT i)cPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ duly 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r+ DATE DATE REMITTED 'L}r AMOUNT <br /> L FEE <br /> f LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y <br /> OTHER <br /> Received by Date - Receipt No. Perini No ssuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />