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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. }, <br /> FOR OFFICE USE; <br /> �. APPLICATION <br /> t (For Non-Transferable, Revocablel'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 Ordinance No. 1862 and the rules and regulations of the San <br /> Exact Site Address Joaquin Local Health District. <br /> City/Town <br /> Owner's Name <br /> AddressPhone <br /> . <br /> Contractor's Name �� �, City <br /> Contractor's Address License#a2/�� Business Phone <br /> ��� `� � 'P� Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? <br /> TYPE OF WORK (CHECK): NEW WELLA DEEPEN ❑ Yes No <br /> WELL CHLORINATION C1RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ UMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ P <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Fieid � • Cesspool/Seepage Pit <br /> Other <br /> Property Line-2 U_Private Domestic Well_Z4V Public Domestic Wel! <br /> ❑ INDUSTRIAL TYPE OF WELL <br /> w CABLE TOOL Dia. of Well Excavation <br /> S.DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing �� <br /> Ll DOMESTIC/PUBLIC <br /> © IRRIGATION ❑ DRIVEN Gauge of Casing G 1 <br /> ❑ CATHODIC PROTECTION '' GRAVEL PACK Depth of Grout Seal " <br /> ElDISPOSAL -ROTARY Type of Grout <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> PUMP INSTALLATION.- Surface Seal Installed By: ` <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Wel! Diameter ' <br /> Describe Material and Procedure Approximate Depth r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County +ff <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certlfies the following:1 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 per subject to workman's compensation laws of California." <br /> I <br /> I will call for Grout Inspection-Prior to grouting and a final inspection. <br /> Signed X " <br /> Title: i � <br /> (prow Plot Plan on Reverse Side) Date: <br /> FOR DEPARTMENT USE ONLY f <br /> PHASEI � - <br /> Application Accepted By �sp�� <br /> Additional Comments: Date <br /> Phase II Grout Inspection <br /> Inspection 8y r y ,Phase III Final Inspection <br /> Date � —�SZ - ,Inspection B <br /> .Date <br /> Fee Is Due: ❑ ANNUALLY <br /> El PER UNIT I ❑ PER SITE EACH ❑ January 1 &ReceiveJanuar <br /> I. d B y y 31 "❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE g REMIT <br /> ! DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE � � AMOUNT <br /> LESS <br /> 3� <br /> PRORATION <br /> 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Dater Y <br /> Receipt No. Permit No. I suance'Date <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES � Mailed ` Delivered 3.. <br /> - 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 –SI <br />