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Applications Will Be Processed-When Submitted Properly Completed. Be SureTo SignTheApplication. <br /> �oR <br /> 0- ICE liE: -' x APPLICATION <br /> t (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Ordi ante No. 1862 and the rut s grid regulations of the San J aquin Local Health District. <br /> ' Exact Site Address r �3 City/Town - ' * <br /> I O� <br /> f Owner's Name Phone <br /> Address r� r,��'�� City <br /> Contractor's Name License# 33 f ( Business Phone <br /> Contractor's Address 4 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 ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ �R <br /> REPLACEMENT❑ <br /> k <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 /> ❑ !>MSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f DOMESTIC/PRIVATE ❑ DRILLED Dia: of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> f ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout p <br /> f ❑ DISPOSAL ❑ OTHER Other Information .t <br /> 'El GEOPHYSICAL Su face Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> ID <br /> Type of Pump r H,P. I <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done t <br /> El State Work Done <br /> PUMP REPAIR: ; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure , <br /> i <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 •District. . <br /> n Home owner orlicensed agents 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-mariner�as to.become-subject to-workman's compensation laws of California." <br /> Contractor'ili ring or sub-contracting-signature certifies the following:"I certify that in the performance of the work for which this <br /> t permit is issued, I shall employ persons subject to workman's compensation laws of Califdrnia. <br /> i I will a Grout Inspection prior to grouting and a final inspection. <br /> Signed X —: Title: Date: <br /> F (Draw Plot Plan on Reverse Side) <br /> l FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ' 14t Date <br /> Additional Comments: <br /> Phase II Grout Inspection Kate III Final Inspection <br /> Inspection By Date Inspection By Date 314 <br /> f <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv d By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ I AMOUNT DUE CHECKED <br /> DATE DATE -REMITTED { AMOUNT <br /> FEE 5 <br /> k LESS ri <br /> E PRORATION <br /> s <br /> PLUS <br /> PENALTY _ <br /> s OTHER w. <br /> i OTHER <br /> Received by Date Receipt No. Permit No. Istuande Date Mailed - Delivered <br /> x,APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ,�y ++` ' 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON.-CA 95201 <br />