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Applications Will Be Processed When SubmittedProperly compleiea. se sure rvaryrr Ir,z.,NY1,..o-1• �I <br /> FOR OFFICE uSE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) �I <br /> PUMP&WEL1. 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 County rdinance No. 18112 a d the rules and regul tions of the San Joaquin Local Health District. <br /> Exact Site Address s� City/Town <br /> Owner's Na;T Phone -7 <br /> Address City <br /> Contractor's Name License Business Phone <br /> Contractor's Address Emergency Phone g <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IJ DEEPEN ❑ RECONDITIONe DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ �y <br /> REPLACEMENT -L� <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 /> ❑ INDUSTRIAL ❑ 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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i 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 <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 perforfyT ance 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 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 In pection prior to grouting and a final inspection. <br /> 6 7 <br /> Signed X _� Til1e: : Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .-,. <br /> Date V" <br /> Application Accepted By — <br /> Additional Comments: - — <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE= <br /> LESS <br /> PRORATION <br /> PL4JS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -11 LI t jc�/kj 7 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />