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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFF!FE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> i ENVIRONMENTAL HEALTH'PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TPLICATE) rr ,f `�3L*"*Ts <br /> RI <br /> Application is hereby made to 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 with San Joaquin Count Ordinance No. 1862 and the rules andregulations of the San Joaquin Local Health District, <br /> Exact Site.AddressCity/Town <br /> Owner's Name <br /> Address City s,e. <br /> Contractor's Name �. License#_336rtng i Bess Phone7. <br /> � N <br /> Contractor's Address 6 r' !`' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ 'DESTRUCTION' <br /> ❑ T` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.❑ OTHER ❑ PUMP-INSTALLATION_. PUMP REPAIR❑ Y <br /> REPLACEMENT❑ <br /> 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 TYPE OF WELL <br /> ❑,,..,�INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L� 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 <br /> f ❑ DISPOSAL : ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump �Ji�� H.P. [/1 <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> CA <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 Sari 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 /> F <br /> I will cal a Grout Insp ion prior to grouting and a finabinspection. <br /> Signed .ter Title: _ Date: / <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE:ONLY <br /> PHASE 1 Date <br /> Application Accepted By <br /> Additional Comments: . ,' <br /> Phase II Grout Inspection Phapill F' Inspection <br /> - Inspection By Date Inspection By Date - ..</ - <br /> ' Fee I$Due: ❑ ANNUALLY ❑:PER UNIT ❑ PER SITE ❑ EACH:'- ❑ January 1 &Received By January 31 ❑ July 1 &Received By,July 31 <br /> REMIT <br /> l: BILLING-. REMITTANCE $' <br /> BASE:' EXPLANATION AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED u AMOUNT <br /> FEE 1 <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> . v <br /> OTHER <br /> Received by Date Receipt No. x Permit No, ssuan -Dat Mailed Delivered-- <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON-AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />