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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> y FOR OFFICE-USE: APPLICATION <br /> �,M (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I— f J I–f <br /> Application is herebyrnadeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance San Joaquin County Ordina a No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address S s City/Town Z1 J <br /> Owner's Name s/e Phone `- �5> i <br /> Address <br /> City <br /> Contractor's Name ` <br /> License# � Business Phon <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes----& No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION � F <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER 1:1 PUMP INSTALLATION Ya_ 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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ;�-nMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 11 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL c Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a� <br /> Type of Pump H.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 ProcedureI <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, N <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will all for rout Inspection prior to grouting and a final inspection. <br /> Signed <br /> Title: +_ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR OEPARTMENT SE ONLY <br /> PHASE I 7 z/go <br /> Application Accepted By Date <br /> Additional Comments: <br /> IV <br /> Phase II Grout Inspection PI se I Final Inspection <br /> Inspection By Date Inspection By Date 1 _106t <br /> Fee Is Due: ❑ ANNUALLY D PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE GATE REMITTED <br /> AMOUNT <br /> FEE 5, i <br /> LESS <br /> PRORATION Ilk <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 � <br /> Received by Date Receipt No permit No. Issuance Date Mailed 06livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 T <br />