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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR aFFrcE USE,. APPLICATION <br /> • <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 <br /> made in compliance with n Joaquin County Ordinance No 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name nse# Business Phone <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �C; No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI <br /> r <br /> REPLACEMENT 11 <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 /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> G <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor (i l <br /> Type of Pump H p <br /> PUMP REPLACEMENT: -�❑- e Work-Done r <br /> PUMP REPAIR: L `tate Work Done aft ea ol .09 <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> ,4.- 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;Viand 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." <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 w•I call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X ~� �" Title: <br /> Date: <br /> (Draw Plot Plan on Reverse-Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date ` <br /> Additional Comments: <br /> Phase It Grout Inspection h III Final Inspection <br /> Inspection By Date Inspection By ate / r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH f ❑ January 1 &Received By January 31 <br /> El July 1 &Received By July 31 <br /> BILLING+ REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> J <br /> OTHER i <br /> OTHER <br /> { <br /> `7 9—1 <br /> Received by ` Date Receipt No. -Permit No Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALC:COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON-AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />