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Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: i APPLICATION <br /> - (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> App ication 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 /> M <br /> e in compliance with San Joa pin County Ordinance No. 1862 and the rules and regulations of the Sann Joaquin Local Health District. <br /> act Site Address I�. 7 City/Town <br /> Owner's Name '� Phone <br /> Address <br /> Contractor's Name License# Business Phone_ Z 6 <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> YPE OF WORK (CHECK): NEW WELL C3 DEEPEN 11 RECONDITION❑ DESTRUCTION <br /> W LL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ (N <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 i TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 /> ❑ pISPOSAL ❑ OTHER Other Information00- <br /> ❑ GEOPHYSICAL i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ! Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done J. n <br /> DESTRUCTION OF WELL: Well Diameter V"' 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 /> Home owner or licensed agent's signature certifies 1he 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 signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 4 i call for a Grout Inspection prior to grouting and a final inspection. <br /> i <br />` Signed Title: - Date: <br /> 1� (Draw Plot Plan on Reverse Side) <br /> k - <br /> !! <br /> _FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Application Accepted Byi Date <br />' Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> 1 Fee IS Due: 13 ANNUALLY PER UNIT ElPER SITE ElEACH 13January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> f <br /> RE <br /> BILLING REMITTANCE $ <br /> MIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED" <br /> UI � AMOUNT <br /> FEE <br /> LESS l' <br /> I PRORATION <br /> PLUS I <br /> PENALTY IM <br /> ``I V R,rIr <br /> I OTHER II <br /> OTHER <br /> ,$ 2d 3 / 37 S"Ca '- <br /> Received by I Dale k Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> ` J APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo■2409 STOCKTON,CA 95201 <br /> i SIM <br />