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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) S, `�l T WATER QUALITY5. d ` dD <br /> Application is hereby made to the SanJoaqulnLocalHealthDistrictforapermittoconstructan / nnstallthework herei M.. rie This application is <br /> made in compliance with n Joaquin County Ordi n e N 862 y nd the rule rig lations of the San,jfiaqun Local lth District. <br /> Exact Site Address / c e ��- City/Town <br /> Owner's Name re r Phone <br /> Address City C �� <br /> Contractor's Name ens. Business Phone � Z <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A-."- No <br /> TYPE OF WORK (CHECK): NEW WELL Ih DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONAg" PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank lQ0 Sewer Lines /010 Pit Privy <br /> Sewage Disposal Field s Cesspool/Seepage Pit /!J� r 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 `� 'A <br /> ❑ DO ESTICIPUBLIC DRIVEN Gauge of Casing 40a rG <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 0 CATHODIC PROTEI TION ROTARY Type of Grout l'eAnzeo!,;­ <br /> ❑ DISPOSAL OTHER, .` Other Information <br />� ❑ .GEOPHYSICAL ._ � Suria <br /> Sf:al Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. L <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> pescribg Material and Procedure <br /> 1 hereby certify that I have"prepared this application and that the work will be done in accordance with SaTt Joaquin County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed ager is 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 /> ContraCtoes 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 wijLgall for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: ^� Date- <br /> (Draw <br /> (C)raw Plot Plan on Rever Side) <br /> t FOR SEPARTMENT USE ONLY <br /> PHASE I n_ ` \�'' <br /> Application Accepted By Date <br /> Additional Comments: <br /> ak,? uttion as Finan Inspection d� <br /> Inspection 6 te — � Inspection By Date <br /> )01 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedBy January 31 Q July 1 &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 <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 85201 <br />