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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. rr <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) a.WATER QUALITY • ' " <br /> Application is hereby made to the San Joaquin Local Health District"for a permit to construct and/or install the work,herein described.This application is <br /> made in compliance wl S Joa uin C r.my Oj Inan No. 1862 and the rules and regulations of the San�pa in Lo al ealth District. . <br /> Exact Site Address �— City/Town <br /> Owner's Name ' Phone --Z <br /> Address City <br /> Contractor's Name icense#�/fL4'L/ Business Phone_ "-,z�7 <br /> Contractor's Address 4` Emergency Phone �d78 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes "f No p� <br /> TYPE OF WORK (CHECK):J NEW WELL❑ DEEPEN 13 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENJ;&-- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage,Disposal Field Cesspool/Seepage Pit Other s V <br /> Property Line t Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER OtherJnformation <br /> ❑ GEOPHYSICAL Surface`Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: 0 —State Work Done <br /> j <br /> MP REPAIR: ❑ State Work Done r PUMP t� <br /> DESTRUCTION OF WELL: Well Diameter —,,Approximate Depth <br /> Describe_Material and Procedure - # <br /> I hereby certify that I have prepared.this.applicatio'n and that the work will be done in accordance with San Joaquin County Q <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> i Home owner or licensed agent's signature certifies the following.111 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 will II for a Grout Inspection prior to grouting and a final inspection. ,! <br /> Signed XTitle: t Date: �Z— <br /> t + (Draw Plot Plan on Reverse Side) <br /> k i FOR DEPARTMENT USE-ONCY' ��" D <br /> PHASE I <br /> Application Accepted By f/d Ctl � Date <br /> Additional Comments: .� � <br /> Phase II Grout Inspection --Phase III Final inspection <br /> Inspection By Date . Inspection B G - � Date -� gZ <br /> l <br /> Fee Is Due: C3 ANNUALLY [I PER UNIT 11 PER SITE ❑ EACH '❑ January 1 8 Received By January'-2i July 1 &Received By July 31 <br /> REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE LESS <br /> ~f <br /> PRORATION <br /> PLUS F a k <br /> PENALTY <br /> OTHER K <br /> OTHER <br /> Received by .. -Date- - Receipt No, -" Permit.No. - Issuance Crate Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Bo=2009 STOCKTON,CA 95201 <br />