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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 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 an oa uin County r inance No. 1,862 a d the_DAes and reg lations of the San Joagyl+rLocal Health Dis ct.. <br /> /Exact Site Address City/Town r <br /> Owner's Name + a: Phone <br /> Address ' ' City <br /> Contractor's Name `.�f �" 'cense# Business Phone <br /> Contractor's Address <br /> t ;I Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ TM DEEPEN ❑ RECONDITION 11DESTRUCTION❑ _ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATIOIaI'12' PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line 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,--- D,CABLE TOOL• - tia. of-Well Excavation -- — - - <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 1:1DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> FbtIRRIGATION -0 GRAVEL"PACKDepth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information - <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMPOINSTALLATION: Contractor <br /> �. Type of.Pump <br /> PUMP REPLACEMENT: ❑ State Work-.Done <br /> PUMP REPAIR ❑ State Work pone <br /> DESTRUCTION OF WELL: Well Diameter Approxlmate_Depth <br /> :f Describe Material and Procedur j <br /> hereby certify that I have prepared this ps as plication an hat he work will be done iK'accordance with`San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> .3 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance thework forwhich this permit <br /> is issued, i shall not employ any person in such manner as to become-subject to workman's,compef sation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of_he work for which this <br /> per�rlit is issued, I shall employ persons subject to workman's compensation laws of California." . 4 <br /> I� for a Gro nspectio grouti a final inspectlon. <br /> V <br /> r Title: <br /> Signed.X - `: <br /> (Draw Plot Plan on Re Ase Side) <br /> © FOR DEPARTMENT USE ONLY <br /> PHASEI l ' <br /> Application Accepted By - Qj�p0 Date, '+ <br /> Additional Comments: <br /> Phase 11 Grout Inspection s _RJbase III Final Inspection <br /> Inspection By <br /> Date Inspection ByT Date 3� <br /> Fee IS Due: 11r ANNUALLY ❑ PER UNIT -❑ PER SITE, ❑ EACH c ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> REMIT <br /> "EXPLANATION - BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE <br /> DATE DATE REM$TTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS - <br /> PENALTY t <br /> OTHER <br /> OTHER r <br /> Received by --Date Receipt No. - Permit.Np. - -Is uanc Date Mailed' - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFR <br /> MIT/SERYICEs 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTDN,CA 95201 <br />