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Applications Will Be-Processed When Submitted Properly Completed.BeSureTosignTineAppncaitvn. <br /> FOR&FILE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT -- — � <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) N. �. <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/onnstall the work herein described This application is <br /> made in compliance with San Joaquin County Ordinance o.1862_and the rules and regulations;of theSanJoaquin Local H lth District: <br /> ;.. i� PIW City/Town <br /> Exact Site Address— - <br /> Phone <br /> Owner's'Name <br /> � r <br /> Address r2.1 �` � City <br /> Contractor's Name Licehse# <br /> Business Phone ' <br /> Contractor's Address ' �Emergemcy Phone" ' n <br /> I' is Certificate of Workman's Compensation Insurance on Fi With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): `NEW WELL❑ -DEEPEN❑ RECONDITION❑ DESTRUCTIONS <br /> WELI_•CHLORINATION C3 WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank' Sewer Lines Pit Privy S- <br /> ` Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ iNp&9fRIAL ❑ CABLETOOLDia. of Well Excavation <br /> OMESTIC/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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> Ri <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca I f r rout insp5-9 prior to grouting and a final inspection. . 4, <br /> Title: Date: <br /> Signed <br /> t f (Draw Plot Plan on Reverse Side) ' <br /> j FOR DEPARTMENT USE ONLY a <br /> PHASE I � <br /> Date <br /> Application Accepted By <br /> Additional Comments: ! <br /> hAse 11 Grout Inspection Phase ill inal In; Ip <br /> Inspection By Date R Inspection By ate <br /> Fee IS Due: ❑"ANNUALLY- '« '❑ PER UNIT` ❑ PER S4TE -�❑ EACH ❑ January i &Received By January 31 - ❑ July 1 &ReceivedREMIT EACH <br /> uIy 3 <br /> i + ` BILLING ,,. .REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE, 'EXPLANATION DATE DATE REMITTED AMOUNT - <br /> , t <br /> FEE .6 a <br /> LESS <br /> r PRORATION <br /> PLUS- , <br /> PENALTY- ; <br /> OTHER <br /> OTHER <br /> ... Received by- <br /> Date Receipt.NO" = Permit No - Issuance Date Mailed;. .. ' Delivered, - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 S.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />