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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 /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described.This application is <br /> made in compliance,with San J/oaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ,�L / �, 5 �s H � �,� , City/Town <br /> i <br /> g, IOwner's Name 711A >_�d Phone <br /> Address � - City <br /> Contractor's Name - License#�.�s S�,�1 Business Phone <br /> Contractor's Address t;1 "r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Ath SJLHD? Yes No <br /> TYPE OF WORK (CkCK): NEIN WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,N❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i1 <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 /> ❑ IND4:fSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing j <br /> x <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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I' ❑ State Work Don <br /> PUMP REPAIR: 1 ❑ State Work Done <br /> DESTRUCTION OF WELL, Well Diameter -. Approximate Depth <br /> r <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 /> Homeowner 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 not employ any person in such manner as to become subject to workman's compensation laws of California." 1 <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 /> 1 wil f r Grout Inspection prior to grouting and a final inspection. e <br /> e <br /> Signed X Title: b-C-tJta.eit Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase III FiI _D <br /> Inspection ' <br /> r <br /> Inspection By Date Inspection By Dated11 i <br /> I <br /> I <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> „ AMOUNT � <br /> i <br /> FEE M <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER $ <br /> ;Received by Date II Receipt No. Permit No. Iss ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 y <br />