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Applications Will Be Processed When Submitted Properiy Completed. Be Sure To Sign The Application. �. <br /> FOR'�)�'Flc ISE: <br /> 4 APPLICATION 'S <br /> (For Non-Transferable, Revocable,Suspendable) \ <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> { f <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 i�.' <br /> made in compliance with San Joa uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town y <br /> Owner's Name w Phone <br /> Address City t <br /> Contractor's Name G License#,�f� Business Phone 2-3 "`7y/4' l <br /> Contractor's Address 7 s,� 6 Emergency Phone " <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t/ No <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION❑ 61 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ fi <br /> REPLACEMENT❑ ` <br /> I 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 1 TYPE OF WELL } <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> WDOMESTIC/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 /> ❑ OTHER Other Information <br /> 13 DISPOSAL o� <br /> ❑ GEOPHYSICALeSurface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor ,— <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work DoneJ' <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 /> 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 forwhich this <br /> {` permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> Ep I will Cali for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ ., l�--ear— — Title: � i, Date: <br /> t (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASEI la _ <br /> Application Accepted By V Date <br /> Additional Comments: <br /> Phase II Grout Inspection P se I Fina spection <br /> Inspection By��� - Date Inspection By ate 2 $� <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 /> IBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE / <br /> LESS I <br /> i PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />