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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oFFicE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) /PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> J <br /> WATER QUALITY(COMPLETE IN TRIPLICATE) , <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoaquinC Count �= rdinan a No. 18 `i- the rules and regulations of the San J quin Local Health District: <br /> Exact Site Address � L ' City/Town <br /> Owner's Name <br /> Phone C' <br /> Address . t97Lqs�f,ne <br /> " <br /> Contractor's Name ` License#/ ie <br /> r (57 <br /> Contractor's Address :J�. v Emergency Phorie ''' 7�. 6: <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No a <br /> TYPE OF WORK (CHECK): — 'NEW WELLI3 DEEPEN ❑ T RECONDITION-[]"" DESTRUCTION❑ It <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> /19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> E <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 /> f 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 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I 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 for Grout Inspection prior to grouting and a final inspectto . •• <br /> Signed X /� r' r - Title: _ _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 .j~ .,t <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection It I fnal Inspection�r�.2a <br /> Inspection By. .Date Inspection.By d+ 'Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ AMOUNT <br /> FEE <br /> _ s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No.- - Permit No. - Issuance Da a Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />