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Applications Will Be Processed When Sulimitted Properly Completed. BeSureTo sign <br /> FQR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 with San Joaquin County Or "Hance No. 1862 n the rules and regulations of the San Joaquin Lo' al Health District. <br /> Exact Site Address City/Town E " 1 <br /> Phone <br /> Owner's Name ►4- <br /> City <br /> Address <br /> Contractor's Name License#�� Business Phone T, - <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—X NO <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank + Sewer Lines �7� Pit Privy + <br /> Sewage Disposal Field 0 Cesspool/$eepage Pit Other <br /> Property Line,/ I - Private Domestic Well .�� + Public Domestic Well 1 <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 <br /> ❑ DRIVEN Gauge of Casing IRRIGATION 11❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: Ae Z-9— <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done m <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 /> r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> j <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 si nature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ person subject to workman's compensation laws of California." <br /> I wqcAll for a Gr t In tion rh to grouting and a final inspection. f <br /> I <br /> Signed X Title: <br /> Date: <br /> " (Draw Plot Plan on Reverse Side) <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection hose III Final Inspection <br /> r <br /> Inspection By Date Inspection Date <br /> . Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January & ceived By January 31 ❑ July 1 &ReceiveRdEBlyiJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE / <br /> LESS <br /> PRORATION <br /> a, <br /> PLUS <br /> y PENALTY <br /> 1 OTHER <br /> OTHER <br /> • <br /> Date Receipt No. Permit No is ante Date Mailed Delivered <br /> Received by . <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />