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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF"rCE USE: APPLICATION <br /> (For Non-Transferable, Revocable Suipendable) <br /> ._. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> {COMPLETE IN TRIPLICAT - - WATER QUALITY ,.�` ��'_3u-IX i <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 /> made in compliance with San JoaLq�u ount Ordinance No. 1862 and the r les and r gulations of the San o quin Local Health Distric . <br /> I Exactte Address Z ty/Town <br /> 5 -� p� -J Phone <br /> Own1 Name 1 �45 <br /> � �`� <br /> Addre;ts City— + �� <br /> Contractor's Name License# 1� _ Business Phone <br /> Contractor's Address Emergency Phone <br /> k Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> P TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> rI DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r <br /> f <br /> Sewage Disposal Field <br /> g p Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF-WELL Al <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _ <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <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 /> r <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �- <br /> f <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 /> r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> t <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 /> I will call for a Grout Inspection <br /> spection prior to grouting and a final inspection. <br /> Signed X ti � Title: ` Date: ` <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `'q— <br /> Application Accepted By d DateO�-/q- <br /> Additional Comments: I <br /> Ph II out Inspectiona! inspection <br /> G "! Phase Ili Fin •� <br /> Inspection B 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 /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S [ 3 <br /> LESS ' <br /> PRORATION k <br /> i PLUS <br /> PENALTY <br /> OTHER <br /> OTHER' a i <br /> l f <br /> Received by I baTe I Receipt No. Permit No. Issuance Date Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />