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Applications Will Be Processed When Submitted Properly Completed. tieSure Iosign Ine-ppilta►wn. <br /> FOR OFFICE USE: APPLICATION 1`"T V ` <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to constructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou Ordinance No. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> r City <br /> Address (- <br /> Contractor's Name License ff33��t.- Business Phone S y <br /> Contractor's Address 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,,❑ !.l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 13 PUMP INSTALLATION 1l— PUMP REPAIR❑ IN <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 /> ❑. 1N STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> El-tOMESTIC/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 4�' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �} <br /> Type of Pump -4,e 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 v <br /> 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 forwhich 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 will c ora Grout Inspe ion prior to grouting and a final inspection. <br /> Signed X Title: 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 11 Grout Inspection h e I Final Inspection <br /> inspection By Date Inspection By 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 /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Is 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 />