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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT �$ r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i <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 C ity Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .�? City/Town <br /> r �..^ < / <br /> Owner's Name &A,(, -' Phone all <br /> Address �} _ � � City <br /> Contractor's Name C _��� License#,2� Business Phone <br /> Contractor's Address 45r..f= Emergency Phone-- r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 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 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit . Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL .v <br /> 0STRIAL STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> [J�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i1/3 <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: I <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. : <br /> PUMP REPLACEMENT: ❑ State Work Done !!! <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ! <br /> I <br /> I 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 /> Homeowner or licensed agent's signature certifies the following:"t-Certify that in the performance of the work for wh"ich'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." k <br /> Contractor's hiring or sub-contracting signature certifies the following:Jcertiify-that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation law's of California." <br /> I will ca fo a Grout ction prior to grouting and a final inapectio^ n. <br /> Signed X. Title: Z41 Date: <br /> (Draw Plot Plan on Reverse Side)' <br /> *" FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> l �� t <br /> Application-Accepted-'By- —.. _ _ _- -_ -- - Date <br /> Additional Comments: <br /> ? Phase II Grout Inspection ` ^Phas'Ifl- final Inspection e1_ y/ wry <br /> Inspection By Date Inspection By Date / <br /> Fee Is DUe: ❑ 'ANNUALLY ❑ PER UNIT! ❑ PER SITE 11 EACH 0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ,BASE EXPLANATION DATE DATE RWITTED PIZ AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r V <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> 1 <br /> OTHER <br /> k <br /> "...,,:..Received by .. Date Receipt No. rermit No. - Issuance Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />