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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> �FOR'OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> �- PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY M <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 i <br /> made in compliance with San JOB in C 51t r mance 186 and the rules and regulations of the San Lo I ealt.11 h District. <br /> Exact Site Address CityJTown � <br /> r <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name )License# r Business Phone <br /> Contractor's Address L Emergency Phone r <br /> Is Certificate of Workman's Compensation In ranee on File With SJLHD? Yes No ` <br /> TYPE OF WORK (CHECK): NEW WELL E] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ " <br /> WELL CHLORINATION ❑ WELL AB'A�ONMENT 11 OTHER ❑ PUMP INSTALLATIONk PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank #Ik Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 11a' <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE F TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation crl' <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 <br /> ❑ DISPOSAL 11 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:1 <br /> PUMP INSTALLATION: Contractor <br /> r.... ...�,�� TYpe bf Pump , r. ..- - „��... _- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ` ❑ State Work Done <br /> DESTRUCTION OF WELL: 1 Well Diameter Approximate Depthti� r <br /> 'Describe Material and Procedure <br /> r <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:owing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ ariy person i'n such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature ceiiifies the following:"I certify that in the performance of the work forwhich this <br /> r permit is issued, I shall employ persons subject toW o#kma ini <br /> s compensation laws of California." s <br /> III call for a Grout I spection;prior grouting and a final Inspection. <br /> Signed X _ _ Title- <br /> (Dr w <br /> itl(Draw Plot Plan on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application ion Accepted By "- "— Date <br /> Additional Comments: <br /> a I Grout Inspection Phase Inspection <br />+ Inspection By Date Inspection By J= Date <br /> Fee 15 Due, ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 5 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DuE CHECKED <br /> DATE DATE REMITTED C AMOUNT <br /> FEE <br /> l <br /> LESS. <br /> PRORATION <br /> + PLUS - <br /> PENALTY <br /> OTHER C� <br /> OTHER - <br /> 1 19'7 <br /> V ,�11(74i X53 "79 l�s� Il/ZY <br /> Ii Received by Date Receipt No Permit No. Issuance Date Maile Delivered <br /> i. - �APPLICANT—RETURN ALL COPIES TO: .;4ENVIRONMENTAL HEALTH PERMIT/SERVICES- - 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 952011 <br />