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,.- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> i - <br /> (COMPLETE IN TRiPLICATE) i � WATER QUALITY <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 wi h San Jo Ilquin Cou ty Ordinance No. 1862CA yd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ll <br /> City/Town <br /> Owner's Name, Phone <br /> Address City A� OBJ <br /> Contractor's Name q' 4 License# Business Phone . <br /> Contractor's Address 1 I Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 14 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA IR❑ <br /> REPLACEMENT❑ &W1Uof- <br /> DISTANCE TO NEAREST: SepticTankSotewer Lines Pit Privy <br /> t <br /> Sewage Disposal Field <br /> 9 p Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well a <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑.DRIVEN Gauge of Casing _ <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> i ❑ CATHODIC PROTECTION i� JM ROTARY Type of Grout <br /> ❑ DISPOSAL I I ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: j ' Contractor <br /> I I Type of Pump H.P. <br /> PUMP REPLACEMENT: i ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ! Well Diameter <br /> I � 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 Count <br /> ordinances, state laws,l�and rules and regulations of the San Joaquin Local Health District. y <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit .J <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout I lspection prior to grouting and a final inspection. <br /> Signed X Title: 4 7"LA 2/L_ <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY j <br /> PHASEI <br /> Application Accepted By Da <br /> Additional Comments: <br /> I� I <br /> Phase It Grout Inspection Pt ase III Final Inspection�7 <br /> Inspection By �� Date Inspection By Date /,Z! <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE � EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT k <br /> I� l <br /> - FEE <br /> LESS rl� <br /> PRORATION <br /> PLUS III <br /> PENALTY <br /> OTHER <br /> OTHERI1 A <br /> D <br /> Received by Date e� Receipt No. Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPT I!TO:i ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,;P.O.Box 217119 STOCKTON,CA 95201 <br /> dl I Qla <br />