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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION /—o7 —. ab, <br /> (For Non-Transferable,Revocable,Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ; <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wito San Joaquin County Ordinance o.1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address d .a City/Town <br /> Owner's NamePhone : <br /> r <br /> Address City , <br /> Contractor's Name �' Lieen_se#-3_Ss l� Business Phone <br /> Contractor's Address 11 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IJ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,ND- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION i:: 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 /> ❑. IN TRIAL 1:1CABLE TOOL Dia. of Well Excavation <br /> 1;?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 /> ❑ DISPOSAL 13OTHER Other Information <br /> ❑ GEOPHYSICAL w Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump M.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 /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this rprmit <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />' I will I to Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Dater � � <br /> (Draw Plot Plan on Reverse Side) <br />[: FOR DEPARTMENT USE ONLY <br /> PHASE I �i%��" " Z�-�rf <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha 6Il/i nal ection Z <br /> . .Inspection By Date - - Inspection By <br /> 7 / 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 /> ov <br /> FEE 7 O <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> VQ l <br /> Received by Date Receipt No. Permit No - I uance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />