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Applications Will Be Processed WhenSubmitted Properly Gompletea. Isesure Io sign 1neF►ppucauvn. <br /> FOPOOFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 7t/PJ; p( 7 I <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 c��/ <br /> I%We <br /> ce ith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Sits AFf�&A'A r �� '� k� � ity/Town <br /> Owner's Nam Phone <br /> Address City ' <br /> Contractor's Na License Business Phone <br /> Contractor's Address? Emergency Phone <br /> 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 ❑ PJMP INSTALLATION � PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank &VZ, 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 /> ❑ INDU TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> LALqYOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑., DOM�TIC/PUBLIC C1 DRIVEN Gauge of Casing Ell <br /> t-55R ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL S�ceeal Install By: <br /> PUMP INSTALLATION: Contract <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 /> 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 far which this <br /> permi i issued, I shall employ persons subject to w kman's compensation laws of California." <br /> 1 11 for a Gro t Inspection prior gr ting a a final inspectio <br /> Signed X Title: �� Date: <br /> (Draw t Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted B � Dat <br /> Additional Comments: _- <br /> Phase II Grout Inspection Phase III Final Inspection r� <br /> Inspection By Date Inspection B+� ate /' �, 7,y_ <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 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ✓f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt Nd. I PAirmit Ise, <br /> ante ate Mailed Delive <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, 55201 <br /> 4^ <br />