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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFI E USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> - <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance w' an Joa In,.ounty Ordinanc No. 186 and the rules and regulations of the San aquin Local Health District. <br /> Exact Site Address � , ' City/Town <br /> r ! , s� r fi l.,f.,.i <br /> Owner's NamePhone-��} '!� �� <br /> Address c� 3 "�"� City �s <br /> Contractor's Name License ��' 7( Business Phone, <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❑ DEEPEN ❑ RECONDITION El DESTRUCTION t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION 'Ldp PUMP REPAIR❑ f, <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 /> ❑ IND STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> E,'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 y <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> U,. <br /> ❑ GEOPHYSICAL o Surfac_e Seal Installed By: <br /> PUMP INSTALLATION: ContractorJ! z�. c <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ 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 n <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. l <br /> 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 caljjor a Grout Insp ion prior to grouting and a final inspection. ` <br /> SignedTitle: Date: �. ,? <br /> (Draw Plot Plan on Rev r� se Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By � / 't• �_`� <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a Inal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 'R Bf7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />