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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign inegpplicauvrr. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described.This application is <br /> ules and regulations of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin Cou ty Ordinance No 1662 and the r <br /> Exact Site Address City/Town r C <br /> Phone <br /> Owner's Name �- <br /> Address _ -�� �-� ' City <br /> Contractor's Name / License Business Phone <br /> Ca 7 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes KNo v <br /> TYPE OF WORK(CHECK): NEW WELX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank 135 Sewer Lines Pit Privy <br /> Sewage Disposal Field 3 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL /I <br /> 1:1 INDUSTRIAL C1 CABLE TOOL Dia. of Well Excavation <br /> Dia. of Well Casing <br /> DOMESTIC/PRIVATE DRILLED <br /> O� 13 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION XROTARY Type of Grout <br /> ❑ DISPOSAL 13 OTHER <br /> 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 /> PUMPJIEPAIR: ❑ 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 dome 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 fallowing:"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 will call for a Grout inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ Date 11-1.2 <br /> Application Accepted By <br /> Additional Comments: <br /> as 1 t Inspection �� Phase l��al Inspection <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 &ReceiveRdEBnylTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> . r <br /> OTHER OF <br /> OTHER <br /> - _ <br /> Received by loate Receipt No. Permit Nm Isliluance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BoK 2009 STOCKTON,CA 95201 <br />