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F <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR'OFFIC-L-,-USE: APPLICATION " •/.a'—r— j. 2S� <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora"permit to construct and/or instal l,the work h7erein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1802 and the rules and regulations of the San J aquin Local.Health District. <br /> Exact Site Address f Gity/Towns <br /> Owner's Name " t `" �" " j Phone <br /> Address �!a .;,, >t7.= ,,,w City <br /> Contractor's Name License#7272 Business is <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ( � <br /> TYPE OFWORK (CHECK): N"EW WELL❑ DEEPEN"❑ RECONDITION❑ —'DESTRUCTIO,N,❑� V" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 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 /> ❑ <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ,,_,, <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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL c– Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I 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 c ll for a Grout Inspection prior to grouting and a final inspection. + <br /> !J <br /> Signed -- - � Title: Date: <br /> _��GL�. <br /> (Draw Plat Plan on Reverse Side) <br /> FOP DEPARTMENT USE ONLY <br /> PHASE.1 <br /> Application Accepted By / � a'r! _. Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection inal Inspection <br /> Inspection By Date - Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UWT ❑-PER SITE ❑ EACH ❑"January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> .;BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - "- <br /> Received by "Date Receipt NO. Permit No. Issua ce Dallp Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />