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Applications Wlll Be Processed When Submitted Property Completed.Be Sure To Sign The Application <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL J <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) �� i <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in.compliance with San J a Uin County O ince No. 1862 and the rulesn <br /> fd regulations of the San Joa <br /> 11 <br /> naquin Local Health District. <br /> Exact Site Address - _ City/Town <br /> Owner's Name ' Phone <br /> Address ; �• City l <br /> Contractor's Name License# A Business Phone - �'�- <br /> Contractor's Address C�. Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�1 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 S} <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 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 Se nstalled By: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> re <br /> PUMP REPLACEMENT: ❑ State Work Done 1n <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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. <br /> Homeowner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspect' <br /> Signed X Title: Date r-� <br /> (Draw Plot Plan on verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection a 111 Final Inspection <br /> Inspection By Date Inspection By Dale <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 .f <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance.Date Mailed Delivered - <br /> Received by Date Receipt No. Permit No. - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />