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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. M <br /> I, FOR OFFICE USE: a APPLICATION F <br /> i - <br /> (For Non-Transferable, Revocable, Suspendable) 1 <br /> 'r <br /> _ ENVIRONMENTAL HEALTH"PERMIT �p PUMP&WELL <br /> gR <br /> L-ETE IN TRIPLICATE) WATER QUALITY <br /> ^ " n is hereby made tot San Joaquin Local Health District for a permit to construct and/or install the work-herein described.This ap lication is <br /> i made in compliance with San oaquin County O dinance No. 1862 an he rules and regulations of the Sana in Lo al Health District <br /> City/Townp <br /> Exact Site Address c <br /> Owner's Name Phone <br /> Address -- CityA1„� <br /> Contractor's Name df License# Business Phone — 2 q <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 3� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El " <br /> REPLACEMENT❑ �t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other V <br /> Property Line Private Domestic Well Public Domestic Well e <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL �l1 CABLE TOOL r <br /> JR" Dia. of Well Excavation <br /> fiVDOMESTIC/PRIVATE - ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ ` — <br /> GRAVEL PACK Depth of Grout Seal #' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOP_HYSICAL_ _ � "`" <br /> Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done 'E <br /> PUMP REPAIR: ^f ❑ State Work Dane <br /> DESTRUCTION OF WELL: i �- Well Diameter <br /> Approximate Depth { <br /> fDescribe Material and Procedure ..IJ <br /> f 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 /> .ter <br /> Homeowner or licensed agent's signature certifies the following:"I certify that"in the performanceof the wofk'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 performanceof the work for which this <br /> .. permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I will all for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XJ S� <br /> Title: '.� � Date:/ <br /> (Draw Plot"Plan on Reverse Side) <br /> 6 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> i. Application Accepted By $� <br /> Date <br /> Additional Comments: + <br /> - .— a <br /> _,,,Phas 11 Grout Inspection 1 Ph a II Final Insp tion" <br /> Inspection By ate a <br /> Inspection By at <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑APER SITE-, ❑'E'ACH [] January 1 &Received By January;LO Juty 1 &Received By July 31 <br /> BASE EXPLANATION BILLING �RFMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � D�w <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> Received by Date Receipt No. Permit No,. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYICES. - 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />