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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFIGtc USE: i APPLICATION <br /> E (For Non-Transferable, Revocable,Suspendable) <br /> PUMP &WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY P <br /> k Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> I made in compliance with San Joaquin CdurU Ordin ce p1862 nd Vfe rules and regulations of the San Joaquin Local Health District. <br /> I Exact Site Address City/Town <br /> J_ <br /> Owner's Name ' Phone <br /> Address P City <br /> Contractor's Name License#1_2 Busines's Phone <br /> Contractor's Address n 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 /> WELL CHLORINATION 13 WELL ABANDONMENT ❑' OTHER E] PUMP INSTALLATION ❑ PUMP REPAID <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 ,❑ CABLE TOOL Dia. of Well Excavation <br /> + 9DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> j. ❑ 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. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter App ximate Depth <br /> Describe Material and Procedure <br /> i° I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 4, 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 /> `c 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 /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." t <br /> r <br /> I itt- all for a Grout Inspection prior to grouting and a final inspec11' "�, <br /> _ � <br /> Signed X —�` Title: ��-"F—� Date: Ca <br /> (Draw Plot Plan on Reverse Side) <br /> 71FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r Application Accepted By <br /> Date/ <br /> Additional Comments: <br /> Phase 11 Grout Inspection P III Fin Inspection /yy <br /> Inspection By • Date <br /> ` Inspection By Date P , <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 /> F FEE <br /> LESS Yr. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> i, Received by Dale :.,�� „'Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009' STOCKTON,CA 95201 <br />