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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) 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 with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address O O City/down <br /> i Owner's Name Phone aT3S ] D <br />" Address ; �.t.-, r :,y, r city <br /> Contractor's Name License# T 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 C36 <br /> _ESTRUCTION❑ - - <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER III ' PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 01 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy a' <br /> Sewage Disposal Field Cesspool/Seepage Pit 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 /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �- <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ( } <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: CEJ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP-REPLACEMENT: V.State Work Don - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. A proximate 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 <br /> ordinanes , state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> I will c or Grout lnsp tion prior to grouting and a final inspection. ! <br /> Signed X <br /> Title: Dale: <br /> (Draw Plot Plan on Re erse Side) <br /> FOR DEPARTMENT USE ONLY ,, <br /> PHASE <br /> Application Accepted By Dat / <br /> Additional Comments: <br /> Phase II Grout Inspection Phasg If Jinal Inspection 'r <br /> Inspection By - Date Inspection By �/ a�—�T <br /> Date �_: <br /> Fee Is Due: ❑ ANNUALLY ❑ PER 6NIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT . <br /> FEE712 <br /> 00 <br /> LESS r <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date -Receipt No.' -, Permit No. Issuance Date MailedDelivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />