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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ." (For Nan-Transferable, Revocable,Suspendable) <br /> -'/PIJMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY E <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the <br /> work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No,1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address � City/Town � <br /> Owner's Name Phone <br /> Ad d ressjr City <br /> Contractor's Name License#33Ert,( t Business Phone <br /> Contractor's Address jV6-+ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORT( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT 13OTHER E] PUMP INSTALLATION L 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 11 CABLE TOOL Dia. of Well Excavation <br /> E3,150MESTIC/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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump "` H.P. d <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. 1 ' <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." <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 /> I wj0xall for a Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: ''-c _ Date: r � <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By -r Date <br /> Additional Comments: <br /> Phase Il Grout Inspection P se III Fi Inspect <br /> Inspection By Date Inspection By Date <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ` AMOUNT <br /> FEE f1 5 <br /> LESS <br /> 6 PRORATION <br /> PLUS <br /> PENALTY <br /> 4� OTHER <br /> E <br /> OTHER <br /> I Received by Date Receipt No Permit No. 1 suance ate Mailed Delivered ' <br /> FP APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O"Box 20119 STOCKTON,CA 95201 J <br />