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Applications Wlll Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR ff—ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Su-spendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> .X)N <br /> (COMPLETE IN TRIPLICATE) 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 with San Joaqui Count Ordinance No. 1862 and the riles and regLIlalions of the San Joaquin Local Health District. <br /> w Exact Site Address l sty/Town <br /> Owner's Name Phone _ A <br /> Address City <br /> Contractor's Name License# 2;7;!g / Business Phone t9 X4 <br /> Contractor's Address 4&6t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL K 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 /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �� Ap <br /> El INDUSTRIAL CABLE TOOL Dia. of Well Excavation ,tiFt <br /> 41 DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing Al <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 2 • <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t• <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grot <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 42 # <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: " ❑ State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter .2 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 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 c I for a Grout Inspe <br /> '901h pri r 1Rgrouling and a sinal inspect' n. <br /> Signed X Title: l7t'x Dat <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> P as}e 11 ,outtlet1Jion, a 11 Final Inspection 1Inspect�io By 4e f Inspection By Date !�Cru r. n"Fee Is Due: ❑ ANNUALLY ❑ PERUEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE ExPLANATlOf1� DATE 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. . - Issuance Date + Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES-T-0—._ ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />