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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 o transferable, Revocable, Suspendabie) PUMP&WELL z <br /> T 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 an Joaquin County OrdiiRaknce No. 1 62 and,t roles and regulations of the Sa oaquin Local Health DistrI6�: I <br /> Exact Site Address2P K City/Town <br /> Owner's Name ) Phone C <br /> Address City <br /> Contractor's Name License Business Phone <br /> Contractor's Address deu t Emergency Phone ,P:.. :,-� -` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> LPJ <br /> TYPE OF WORK (CHECK): NEW WELL❑ � DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ,y <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> z INTENDED USE TYPE OF WELL 1 <br /> ,❑. I�STRIAL N 11 CABLE TOOL Dia. of Well Excavation <br /> U DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/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: <br /> PUMP INSTALLATION: Contractor <br /> _ I <br /> Type of Pump H.P. – <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> rt <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r. <br /> Describe Material and Procedure j <br /> 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 /> Home owner or licensed agent's signature certifies the following: I certify that in the performance of the work for which this permiti <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." <br /> I will c r Grout In prior to grouting and a final inspection. <br /> � �,+y� Date: <br /> Signed Title: —8�� -� <br /> * (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT E ONLY <br /> V <br /> PHASE I' _ <br /> '.` Date— p <br /> Application Accepted By -OVA ' <br /> Additional Comments: II <br /> Phase II Grout Inspection ., Pha at Inspection f <br /> Inspection By Date--- Inspection By Date Inspection d <br /> Fee IS Due: ❑ ANNUALLY "�`❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 LJ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS II�� <br /> PENALTY <br /> OTHER <br /> OTHER jkh - t <br /> Received byDate's Receipt No. Permit No. Iss ance Date Mailed - Delivered', <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Bo:2009 STOCKTON,CA 95201 <br /> Ems`= <br />