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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication <br /> FOR OFFICE USE: APPLICATION Al.COP47e e <br /> 1w, (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT *r <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q <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 with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address City/Town .� <br /> Owner's Name <br /> Address ' - -- City <br /> Contractor's Name ��-t "`- License#, Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's 6ompensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ 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 Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INRUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/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. i� 11J <br /> PUMP REPLACEMENT: ❑ State Work Do <br /> PUMP REPAIR: ❑ State Work Done ,C <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r' <br /> Describe Material and Procedure <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 /> Home owner 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 wellAqlljor a Grout Inspection prior to grouting and a final inspection. <br /> Signed X e-- Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I <br /> FMENT USE ONLY <br /> Application Accepted By OR DEPA Date <br /> Additional Comments: <br /> Phase N Grout Inspection Phasfi al Inspection � 7 �e <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION 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. Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />