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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> E FOR OFFICE USE: 1 APPLICATION <br /> jE i} <br /> (For Non-Transferable, Revocable, Suspendable) AI <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Applicationishereby madetotheSan Joaquin Local Health District for apermit toconstruct a d/or install eworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin ou�Ord`na� n�e No. 1 62 and a rules and g �ations of the San Joa uin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address -. City <br /> Contractor's Name , License# '� Business Phone <br /> I, Contractor's Address t <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑, RECONDITION❑ DESTRUCTION❑ <br /> f WELL CHLORINATION ❑ WE A .N NMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Q <br /> REPLACEMENTk <br /> DISTANCE TO NEARE Septic Tank" <br /> Sewer Lines. Pit Privy <br /> Sewage Disp;sal Field Cesspool/Seepage Pit _ Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE J TYPE OF WELL. <br /> ❑ INDUSTRIALCABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0 DRIVEN', Gauge of Casing, <br /> ❑ IRRIGATION El GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DI { <br /> SPOSAL ❑ OTHER � <br /> Other Information � <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P r j <br /> PUMP REPLACEMENT: 11 state Work Done a. <br /> PUMP REPAIR: ❑ State Work Done 7 <br /> DESTRUCTION OF WELL: Well Diameter <br /> _ Approximate Depth <br /> ' r 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. L <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit N <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ll <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 shaft employ persons subject to workman's compensation laws of California." <br /> lwRLqall for a Grout nspe tion prior to gr uting and a final inspection, f <br /> Signed X I A, r <br /> Title: /J Date: �� d <br /> (Draw Plot Plan'on Re ver a Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> `' � <br /> Application Accepted'By Date�� <br /> Additional Comments: <br /> ,Phase II Grout Inspection <br /> PM Ill Final Inspection <br /> Inspection By Date - Inspection By Date 6 I <br /> ( <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received y January 31 ❑ July 1 &Received By July 31 <br /> • BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED -AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Yf <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date I Receipt No. Permit No. Ts uance Date Mailed Deliv ed <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 e',4 AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> H <br />