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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> -FOJR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 SSW oaqu' County rdinance No. 1862 and the rules and regulations of the San Jo ,local eplth District. <br /> Exact Site Address �<< Gity/Town <br /> Owner's Name s Phone <br /> Address City <br /> Contractor's Name Li-ense Business Phone <br /> Contractor's Address06 Emergency Phone <br /> Is Certificate of Workman's Compensation Insur a on Fite th SJLHD? Yes No O <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION❑ DESTRUCTION❑/ <br /> WELL CHLORINATION 13WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION ZL- 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 /> ❑ I� �USTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> L7 DOMESTIC/PRIVATE 9.B IILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,❑ G�VEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Syrface Seal Insta d By: <br /> PUMP INSTALLATION: Contractor <br /> t <br /> Type of PumpH.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 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 wi all or a u nspection prior to grouting and a final inspe ti <br /> Signed X Title: S Date: <br /> cf�� (Draw Plot Pian on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ate. Date 6�777 <br /> Additional Comments: <br /> Phase II Grout Inspection a Final Inspection Q <br /> Inspection By Date �I �7� Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 19 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k-7-7 <br /> Received by Date Receipt No. Perm7 <br /> it No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Box 2099 _STOCKTON,CA 95201 <br />