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Applications Will Be Processed When Submitted P operly Completed. Be Sure To Sign he Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.'This application is <br /> made in compliance with San Joaquin Co t Ina ce No. 1862 and the rules an "regulations of the San Joaqui" Local Health District. k <br /> Exact Site Addres City/Town <br /> Owner's Name ? Phone <br /> Address , City ,, a <br /> Contrac#or's Name License# usiness Phone S <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❑_'• 6EEPEN © - RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT-El OTHER ❑ PUMP INSTALLATIONPUMP 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 <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 <br /> �,�Surff�faceal <br /> PUMP INSTALLATION: Contractor U1 <br /> r Type of Pump0 <br /> H.P. <br /> PUMP REPLACEMENT:_ ❑ State Work Done <br /> PUMP REPAIR:, _ ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diatileter Approximate Depth <br /> F <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 s <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. T <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 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 I � Title: Date: 6 <br /> (Draw Plot Plan on Reverse Side) ��y <br /> FORD P RTMENT USE ONLY <br /> PHASE I /- � <br /> Application Accepted By 3 ( Date <br /> Additional Comments: <br /> Phase II Grout inspection e Ina! Inapection� <br /> Inspection By tDate --- Inspecti"on•By. Date <br /> V <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH} ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 " <br /> BILLING REMITTANCE ' .$ REMIT ; <br /> BASE EXPLANATION . AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> S. C"?a r <br /> LESS <br /> PRORATION <br /> PLUS z r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S `3/->-4 '9 <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 />