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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR of� iCE USE: eAPPLICATION <br /> Cd ti"'(For Non-Transferable,Revocable,Suspendable) <br /> / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance o. 1862 and the rules and regulations of the San Joaq 'n I Health District. <br /> Exact Site Address / `a�_� � /& � <br /> City/Town <br /> Owner's Name It v <br /> Address Phone <br /> ity - <br /> Contractor's Name . License# Y� �6� •a`.�r <br /> Contractor's Address Business Phone <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W' h SJLHD? . Yes—X No '— <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REPAIR❑ <br /> REPLACEMENT❑ ob <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> PropertyOther Line Private Domestic <br /> Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> �i DOMESTIC/PRIVATE Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11IRRIGATION Gauge of Casing <br /> El GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER <br /> 11 GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: ! Surface Seal Inst d By: <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work DH.P. <br /> one t <br /> PUMP REPAIR: <br /> ❑ State Work Done (�l <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I 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 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 II w'll call for a Grout Inspection ri t gr 'in anda final inspection. <br /> Signed 1� r S <br /> e: i Date: '? <br /> (Draw Plot Pian on Reverse Side) <br /> PHASE 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted By (�" C),:z Gf �liatr <br /> Additional Comments: ate �� �` <br /> Phase II Grout Inspection <br /> Inspection By �`--� Date Ph a II nal Inspection By--� nspection <br /> Date Inspection By 4Z, <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH El January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ^� AMOUNT <br /> LESS / �S O <br /> PRORATION l <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES suance ate Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />