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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. , <br /> FOR OFFICE USE: APPLICATION t.1r <br /> 0 r- (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT .. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance with San Joagpin Count Ordin. nce No.186 and the rules and regulations of the San Joa in Local Health District. <br /> Exact Site Address City/Town { <br /> J <br /> Owner's Name r Phone <br /> Address 0- City y` <br /> Contractor's NameLicens F +'r Business hone_ t <br /> � i r <br /> Contractor's Address f Emergency Phone S Z S— S <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 /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> a <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ <br /> ❑ DISPOSAL 11 OTHER Other information <br /> ❑ GEOPHYSICAL Surface�#pI Installed By: A <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 /> Home owner or licensed agent's signature certifies the following:"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." T <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this fy <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." , <br /> I <br /> i.Will call for a Grout Inspection prior to grouting and a final inspection. f lr <br /> Signed X Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEi <br /> Application Accepted y Date�-�> 7 <br /> Additional Comment <br /> Phase 11 Grout Inspection Phase III Final Inspection t <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31. <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION, DATE DATE REMITTED <br /> AMOUNT <br /> s <br /> FEE S ��• C7 <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No.,�- , issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />