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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR 4FICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,`Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY a <br /> }. r. <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordi a e No. 1862 a d t �e rules,and regulations of the San J aquin oval Health District. <br /> �-- <br /> Exact Site Address r Cit'/Town ^ <br /> "r Od <br /> Owner's Name Phone <br /> Address f:y City'' <br /> Contractor's Name of�pp j� r (License#3 Business Phone_.Y"_., <br /> Contractor's Address c r �' ' Emergency Phone '"; ' � �- d <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �f No <br /> TYPE OF WORK (CHECK): NEW WELL.. T DEEPEN ❑ 'RECONDITION❑ — DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines . Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit s'� Other <br /> cl <br /> Property Line /9' - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL / ` r ` , <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> P❑,DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f d <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 <br /> P CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL face Seal Installed By: r Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.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 /> r <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." <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 w11Lca1l for a Grout Inspection prior to grouting a .final inspection <br /> � 3 , <br /> Signed X Title: Date: <br /> „ (Draw Plot Plan on Reverse Side) w __ <br /> FOR DEPARTMENT USE ONLYF <br /> PHASE I Q <br /> Application Accepted By % "r Date <br /> Additional Comments: _ 'I <br /> Pha a II grout Inspection Ph a til Final Inspection. <br /> inspection By e _../ -fit` Inspection. <br /> Fee IS Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH`- ❑ January 1 &Received 6y J nu."31 ❑ July t &'Received By July 31 <br /> r REMIT <br /> BASE EXPLANATION BILLING REMITTANCE r$- AMOUNT DUE CHECKED + <br /> DATE DATE REMITTED -AMOUNT <br />' PEE 3/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> `__S PENALTY <br /> OTHER t <br /> OTHER <br /> Received by -Date Receipt No. Permit No. - IssuAtrice Datle Mailed Delivered ) <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2000 STOCKTON,CA 95201 1r! <br />