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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.'! <br /> FOR`OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> Ii <br /> ENVIRONMENTAL HEALTH PERMIT <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> e <br /> made in compliance with San Joaquin County O dinance No. 1862 ang the rules and regulations of the San Joaquin Local Health District. <br /> kd <br /> Exact Site Address UY � City/Town _ <br /> Owner's Name Phone <br /> Address -- City <br /> Contractor's Name License# Business Phone <br /> 01— <br /> Contractor's Address 'Emergency Phone i' <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): ' NEW WELL DEEPEN 13RECONDITION'❑ DESTRUCTION[] � »� <br /> WELL CHLORINATION ElWELL ABANDONMENT El OTHER 11 PUMP INSTALLATION Q—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 /> 1,�1, INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> P'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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 t <br /> Describe Material and Procedure <br /> I hereby certify that 1 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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I willI f r a Grout In ction prior to grouting and a final inspection. <br /> „ Signed X — _ Title: Date: W � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE j � <br /> Application Accepted By Date e <br /> Additional Comments: <br /> Phase II Grout Inspection Phas 11 'nat Comments- <br /> in. <br /> tion <br /> Inspection By Date Inspection By e Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January-t &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE- EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEChi <br /> LESS <br /> PRORATION I ' <br /> PLUS <br /> PENALTY <br /> y,. <br /> OTHER f <br /> OTHER j <br /> / C;) �� a <br /> Received by - -- - Date— - Receipt No. Permit No, Issuahce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.ao■2009 STOCKTON,CA 95201 ` <br />