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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE lsE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> 4 Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein.described.This application is <br /> made in compliance with San J aquin Coui*,Pxdi.Dance No.1862 and the r s and regulations of.the San�Joa uin Local Health District. <br /> Exact Site Address City/Town <br /> r <br /> Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name e 01icense#WA-z"Business Phone <br /> I Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> I - <br /> I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL'CHLORI NATION ❑ WELL -ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy <br /> Sewage Disposal Field CesspooVSe.epage 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 1 <br /> ,.Sat Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> A ! <br /> ❑ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> ❑ iRRIGATION ❑ GRAVEL PACK Depth of Grout-Seal <br /> r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N <br /> ❑ DISPOSAL ❑ OTHER Other Information a <br /> ❑ GEOPHYSICAL00010 Surf ce Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ` El 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 /> i 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 call for a Grout inspection prior to grouting and a final inspection. <br /> Signed X Title: �J� �� Date:/ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY �� <br /> PHASE <br /> Date <br /> Application Accepted <br /> Additional Comments <br /> Phase II Grout Inspection a 111 Fi Inspection Y� n <br /> Inspection By Date Inspection By Date Y �j <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION -BILLING REMITTANCE - $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER � �itff5..._>.•.. .�-i' �fY „; <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 />