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y Applications Will Be Processed When Submitted Properly Completed i3e Sure ioblgn inerappncauvn. <br /> FOR OFFICE USE: APPLICATION , <br /> '�•r (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> 9 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ounty Ordin ce No. 113G9�d the rule nd re ti s of the San Jo Local H th District. <br /> Exact Site Address �� pity/Town <br /> Owner's Name Phone ~, <br /> Address <br /> Contractor's Name License usiness Phone <br /> Contractor's Address Emergency Phone l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WECL®-�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 /> 1 <br /> i Property Line 6-0 Private Domestic Well Public Domestic Well. <br /> INTENDED USE TYPE OF WELL /r <br /> ❑, IND STRIAL 11 CABLE TOOL Dia. of Well Excavation ( _ <br /> LTDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �F <br /> i Cl DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I ❑ IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION A- OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL face Seal Instal By: <br /> 11 <br /> r PUMP INSTALLATION: Contractor <br /> P. <br /> Type of Pump r _.__ _ 33 .- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 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 /> 1 will call for a Grout Inspection prior to out* g and a final Inspection. <br /> Signed X �' Title: /// Date: <br /> L (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY s <br /> PHASE IF Date <br /> Application Accepted By <br /> Additional Comments: <br /> ahfts ll Grout Inspectionp Ae 111 Final Inspection <br /> Inspection By DateI moi, ' bD Inspection By ' Date ✓ <br /> Fee I5 Due: F1 ANNUALLY El PER UNIT -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> � 1 <br /> LESS <br /> F PRORATION - r <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> Date Receipt No. OPermit No. Is an e Date Mailed _Delivered <br /> Receivetl by # <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 - STOCKTON,CA 95201 <br /> w <br />