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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH"PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY1. <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 wit San Joaq .n Co n Ord' ante No. 1862 and th rules and regulations of the San JQalin Local Health District, <br /> Exact Site Address. s City/Town <br /> e. <br /> f _ r <br /> Owner's Name Phone! <br /> Address ' City <br /> Contractor's Name License# Business Phone" <br /> Contractor's Address r;2 A Erriergency Phone' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL©4 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 <br /> ��trr❑,,,fff 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 y ❑. OTHER �. Other Information <br /> ❑ GEOPHYSICAL r Surface I Installed By: <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:., r ❑ State Work Done ` <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a Grout Inspection prior-to grouting and a final Inspection. <br /> i fJ <br /> f Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted �._ _.._.. Date - � <br /> Additional Commen S: t <br /> Phase II Grout Inspecllon h e III Final Inspection i <br /> " inspection By ' Date - Inspection B <br /> �sG �_. Date µ � <br /> Fee Is'Due: ❑ ANNUALLY .r ❑ PER UNIT ❑'PER SITE EACH `"' ❑ January 1 8 Re d By January 31 r ❑ July 1 8 Received By July 31 <br /> {'BASE fit. >1l EXPLANATibN REMIT <br /> BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LES5Fti - I NO$ <br /> PRORATION �b i,i. ta <br /> PLUS <br /> PENALT�Y•r;a-rf. <br /> OTHER ;IV'fl ! <br /> OTHER - i- <br /> i b . R7 <br /> Received by - ate Receipt No. ! -- " Permit No.. ' Issuance Date Maiied Delivered -. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />