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rApplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO,R~:FFICE USE: APPLICATION <br /> (For'Non-Transferat t0,°kie racable, 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 Ordin ce No. 1862 and the ul and regulations of the San,Jaaquin Local Health District. <br /> Exact Site Address City/Town �J <br /> Owner's Name -�•- CC�i�� Phone <br /> Address City <br /> Contractor's Name License#/2 ,� Business donefe- 1 <br /> Contractor's Address Emergency Pho e j <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes_._.. No <br /> TYPE OF WORK {CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORIION ❑ , WELL AB NDO MENT O�❑+ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT �� � 1 <br /> DISTANCE TO NEAR ST: 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 /> DOMESTIC/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 N ; <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 /> r <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure 'y <br /> l <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 forwhich 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 persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspecii n, <br /> Signed X Title: s Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date © <br /> Additional Comments: <br /> Phase 11 Grout Inspection ,,rP�se III Fin Inspection j <br /> Inspection By Date Inspection Byt ( -Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS C� <br /> PRORATION <br /> PLUS c <br /> PENALTY ' <br /> OTHER i <br /> OTHERRflf 47 <br /> S <br /> Received by Date '3_ -`• ecei"jit No- Permit No. .Issuance Dafe - -Mailed Del eyed - <br /> t <br /> APPLICANT—RETURN ALL COPIES TO: ENV ONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ' STOCKTON,CA 95201 <br />