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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> {For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> T ` ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described,This application is f <br /> made in compliance wit aJ yin C unty O inance No. 1 2 nd the rules and regulations of the San J�-Lo�Health District. <br /> Exact Site Address F City/Town <br /> 1 � <br /> Owner's Nae Phone <br /> Address 49 <br /> City <br /> Contractor's Name License Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No (( ' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1J" <br /> WELL CHLORINATION ❑ WELL ABANDONME=NT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ f <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tanks Fiewer Lines Pit Privy <br /> Sewage Dis eld Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL. 11 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 SealOF <br /> y - <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By! � O� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 11State Work Done <br /> PUMP REPAIR: ElState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> 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 /> !rQt <br /> Homeowner 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 ariy 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 for which this <br /> permit is issued, I shall employ r persons subject to workman's compensation laws of California." 1 <br /> 1 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. A J { <br /> Signed X <br /> k Title: Date:, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI 9)// <br /> Date <br /> Application Accepted y s <br /> Additional Comment <br /> Phase II ,rout I spectio Phas III Final Inspection <br /> Inspection By ate Inspection By Date 11 <br /> J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date r Receipt No. Permit No. I Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />