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a Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucat>on. <br /> 3 APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) 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 SaryJoa uin C my Ordinance o. 62 and the rules and regulations of the S in Loc Health District. <br /> Exact Site Address City/Town <br /> .r- Phone <br /> Owner's Name {r �� a. <br /> Address City— -� 42 9�-� <br /> Contractor's IV a Y— <br /> License �Business Phone: <br /> Contractor's Address Emergency Phone Q <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No – VV <br /> TYPE OF WORK (CHECK): NEW'WELL®DEEPEN ❑ . RECONDITION❑ '. DESTRUCTION❑ , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0----'PUMP REPAIR❑ M <br /> REPLACEMENT❑ '" "' ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines m Pit Privy p(2 <br /> Sewage Disposal Fie Cesspool/Seepage Other <br /> Property Line Private Domestic Well ~' Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IWUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION Cl! <br /> ,, GR�VEL PACK Depth of Grout Seal - d <br /> 13 CATHODIC PROTECTION L�`ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other.Information ' 1 <br /> E] GEOPHYSICAL Irface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> F PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth i <br /> Describe Material and Procedure r <br /> I hereby certify that I have prepared this app/+cation 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 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-con cting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> ermit is issued, i shall empl y pe ons subject to workman's compensation laws of California." <br /> w call for a Gro t In ec ' prio to grouting and a final inspection. <br /> Title: • ' Date: <br /> SI <br /> (Draw Plot Plan on Reverse Side) ` <br /> FOR DEPARTMENT USE ONLY (� C <br /> PHASE I <br /> Application Accepted By Date <br /> A f <br /> PP P I <br /> Additional Comments: <br /> P a I rout I nspectipaj r,1 �� - d Phase IW tnal Inspection <br /> Inspection By Date f Inspection By Date <br /> Date <br /> � 9 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ; ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Receiv.dEMIT By July 31 <br /> ' BASE EXPLANATION 'BILLING c REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ( <br /> LESS <br /> PRORATION <br /> PLUS Y <br /> PENALTY_ <br /> OTHER <br /> OTHER " { l• <br /> .-,..._,Received by __.Date.Date ._ .� .Receipt No. � Permit No. �,,. Issuance Date . - Mailed' Delivered.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HA2ELTON AVE.,P.O.Bo:2099 STOCKTON.CA 95291 <br /> KTO <br />