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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 72-- <br /> . (For Non-Transferable,Revocable, Suspendable) PUMP&WELL ` <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) , WATER QUALITY <br /> r: <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is. <br /> made in compliance w' h San Joaquin County Ordir�nce No. 1862 and the rules and regulations of the San Joaquin Local Health District-. <br /> Exact Site Address — City/Town _ <br /> �M : � . <br /> Owner's Name " Phone,. <br /> Address City <br /> .L'7., License# Business Phon 3 <br /> Contractor's Name <br /> Emergency Phone— <br /> Contractor's Address c <br /> is Certificate of Workman's Compensation Insurance on File With_SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK} V NEW WELL❑ DEEPEN❑ '_RECONDITION❑ ' DESTRUCTION❑ — <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ : OTHER 11 PUMP INSTALLATION PUMP REPAIR El r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> y Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN,p STRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> Ul/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 4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Q.1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 4 ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t 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 fallowing:"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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will 11 or a Grout Ins ection prior to grouting and a final Inspection.—.. <br /> JJ <br /> Signed X — <br /> Title: Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE 1 /S � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By (Date 1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ElJanuary1 &Re By January 31 F-1July1 &Received By July 31 <br /> REMIT <br /> BASE, ! EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS s <br /> PRORATION f <br /> PLUS - <br /> PENALTYrIT$ <br /> i <br /> OTHER / <br /> OTHER .� <br /> Received-by Date - Rece+pt No - Permit No. -I nuance ate Mailed- Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />