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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> oR,sr . lcE USE: APPLICATION <br /> — (Fer Non-Transferable, Revocable, Suspendable) P <br /> ) EfAVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE WATER QUALITY O <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 with San Joaquinunty rdi nce No. 1862 and.the rules and regulations of the San JoaLquin Ljoc_al Health District. <br /> Exact Site Address t3 ? City/Town <br /> Owner's Name Phone <br /> Address d City�� _ _ <br /> Contractor's Name j License#�1B Business Phonee� ) <br /> Contractor's Address +01 Gi-If /V Y� - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on f=ile With SJLHD? Yes �'� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �T <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ - <br /> ❑ INPUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> l OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN V-' '--Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK ,I :Depth-of'Grout.Seal <br /> ❑ i <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> YP <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ►, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �t� t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done- r <br /> PUMP REPAIR: .E ❑ State Work Done <br /> DESTRUCTION OF WELL: : Well Diameter -- y Approximate Depth <br /> �J Describe Materia'd Procedure ° <br /> I hereby certify that I have prepared this application and that the work will tie done;in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of theiSan 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 sl§nattire deirtiiies 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 r rout Inspection prior to grouting and a final inspection. <br /> Signed s Title: �i u�v.__- i_ Date: — <br /> (Draw Plot Plan,on'` Ieverse Side) <br /> .� � s <br /> FOR PART NT USE ONLY F <br /> PHASE ' <br /> Application Accepted By i Date Q <br /> Additional Comments: <br /> P s Grout Inspection ; Phase II Final Inspection' I �7 � <br /> Inspection By Date Inspection By �D <br /> Date JJ�I I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑:January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMtT <br /> BASE EXPLANATI N DATE DATE REMITTED AMOUNT DUE CHECKED <br /> I AMOUNT <br /> S/ <br /> FEE <br /> LESS i <br /> PRORATION } - <br /> PLUS <br /> PENALTY <br /> OTHER ~' <br /> OTHER <br /> S <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered e <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 9520 .- <br />