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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.T <br /> R <br /> RFOR'OFFII'USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 11 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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)-ocal Health District. <br /> Exact Site Address j City/Town ��,,,,J _ <br /> Owner's Name C <br /> Address 7 Phone <br /> 7- _ City <br /> Contractor's Name _ License# <br /> � '� � � Business Phone <br /> Contractor's Address n r Emergency Phe <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes. No <br /> TYPE OF WORK (CHECK): NEW WELL 1:1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT R U1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> ,'. Sewage.Oisposal Field Cesspool/Seepage Pit Other t <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE "I TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation { <br /> 06 DOMESTIC/PRIVATE ❑ DRILLEDI <br /> 11DOMESTIC/PUBLIC Dia. Well Casing <br /> DRIVEN Gauge <br /> of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> El CATHODIC PROTECTION ❑ Depth of Grout Seal <br /> ROTARY Type of Grout ' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> A* Type of Pump ��H,P <br /> PUMP REPLACEMENT: State Work Done u �- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ! hereby certify that 1 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:°'1 certify that in the performance of the work for which this l <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will I fo GrounI24epdon prior to grouting and a final inspe. o <br /> j <br /> Signed X { -w -Title: /2`, <br /> l J Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> ASE I FOR DEPARTMENT USE ONLY <br /> A pi" <br /> Application Accepted By _��' I <br /> Additional Comments: Date <br /> Phase 11 Grout Inspection P. ase III Final Inspection <br /> Inspection By Date Inspection B <br /> Date <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8, ivied B Januar 31 <br /> By Y ❑ Jufy 1'&Received By July 31 <br /> BASE" EXPLANATION BILLING REMITTANCE g REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � ( AMOUNT <br /> FEE ..� `! � <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> rn. o <br /> Received by ❑ to Receipt No. <br /> + P Permit No. Issuance Date Mailed Delivered <br />" APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />__ ,N Y 1601 E.HA2ELTON AYE.,P.O-Box 2009 STOCKTON,CA 95201 <br />