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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> k — - (For Non-Transferable, Revocable,Suspendable) <br /> RUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District tora permit to construct and/or install the work,herein described.This application is F' <br /> made in compliance with 99n Joaquin CountyQ5dinance No. 1862 and the rules and reguI tons of the San Joaquin Local Health District. <br /> t Exact Site Address i �� �� / City/Town <br /> " a y <br /> {j Owner's Name Phone <br /> f Address City 1rr� <br /> Contractor's Name License# 3770gi� Business Phone <br /> k Contractor's Address t _ Emergency Phone <br /> f Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 /> t <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑])NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f <br /> Dif 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 ❑ 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 <br /> PUMP REPAIR: ❑ State Work Done ' ' —f _ <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I _ <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. G <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." (� <br /> I: r7 <br /> C Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca for a Grout InspeMaio gro ting and a final InspectI n. , /r <br /> Signed X f F d Title: Date: �U <br /> (Draw Plot Plan on 4everse Side) <br /> �. FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> R Application Accepted By Date 1 <br /> Additional Comments: <br /> Phase 11 Grout InspectionF��Pha fi III Final�nspection � � <br /> Inspection By I Date Inspection By JN Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received Ry January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> :REMITTANCE $ <br /> EASE EXPLANATION BILLING DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> O <br /> FEE 5 �. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> l <br /> OTHER <br /> ? OTHER 3 <br /> l (41 b 3� <br /> ` – Received by Date Receipt No. Permit No. Is uance Pate Mailed Delivered <br /> F APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br />