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NppucatlonsWillBeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. - —� <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.Thisapplication is <br /> made in compliance with San Joa uin Ounty Ordinance No. 1 62 and th rules and regulations of the Sa J aquin Local Health District. <br /> Exact Site Address 1 <br /> ' [tP City/Town <br /> Owner's Name <br /> Address Phone <br /> Contractor's Name " ' City <br /> I License#!::290 7/ <br /> Contractor's Address �pBusiness Phone <br /> ' � � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No J 7 <br /> TYPE OF WORK (CHECK); NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT-0 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1:1 <br /> REPLACEMENT❑ , <br /> f DISTANCE TO NEAREST: Septic Tank �f <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field &26 0'14- Cesspool/Seepage Pit <br />` OtherPro <br /> Property Line Private Domestic <br /> Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> 11 CABLE TOOL <br /> DOMESTIC/PRIVATE Dia, of Well r xcavation <br /> ❑ DRILLED 6 Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATIONGauge of Casing _ /��1C �eze <br /> R GRAVEL PACK Depth of Grout Seal_ <br /> ❑ CATHODIC PROTECTION W ROTARYS� <br /> ❑ DISPOSAL s ❑ OTHER Type of Grout <br /> Other Information d <br /> El GEOPHYSICAL I!# e <br /> PUMP INSTALLATION: - Contractor Surface Seal Installed By: <br /> Type of Pump <br /> PUMP REPLACEMENT: _ ❑ State Work Done H.P. <br /> PUMP REPAIR: ~ ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter / <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify tfiat 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 the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall riot 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, f shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X 12 <br /> z <br /> Title: Date: <br /> (Draw t Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B Ac C-9 <br /> j <br /> Additional Comments: t Date + O( F. <br /> Phase II Grout inspection <br /> Inspection By � h III Final Inspection � <br /> Date Inspection B <br /> Date a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ` <br /> BASE i EXPLANATION BILLING. REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE '3 r' ` AMOUNT <br /> LESS <br /> fy'2 .� <br /> PRORATION <br /> PLUS �{ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l <br /> Received by Dated' <br /> Receipl No. Permit No. Issuance Date K <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - Mailed Delivered' <br /> 1601'E.HAZELTON AVE.;P.O.Box 2009 STOCKTON.CA ss2ev!� _ <br />