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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE-IN TRIPLICATE) WATER QUALITY <br /> Application i"tereby 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. 1852 and ther les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address G! - (�..lty/Town <br /> Owner's Name > Phone <br /> Address City <br /> Contractor's Name License# �fJ r Business <br /> Contractor's Address ? Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No j <br /> TYPE OF WORK (CHECK): NEW WELL% DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /?I` it E, Sewer Lines Pit Privy <br /> Sewage Disposal Field r 01hP- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> n. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing pv <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /66 IV a49-2 <br /> ❑ IRRIGATION Id GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION la. ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 514h— bL <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done {/V <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 /> Home owner or licensed agent's signature certifies 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil tail for a Grout Ins p ion prior to grouting and a final ins ectio q <br /> Signed X Title: Date: �✓ 7 0�- <br /> (D w Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ck— Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection Bya J-41, Date Inspection B 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 AMDUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> AMOUNT <br /> FEE I!(}�� - Un LESS <br /> PRORATION 'tUdoind cv !/6.h�1.[ i P{(j I ew) or Ow1^CY lAt f 4-v <br /> PLUSK <br /> PENALTY rr0(`s'r-l*l y�y� <br /> OTHER <br /> 4% <br /> OTHER U U t.,i <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered , <br /> } APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 1 <br />