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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE use: APPLICATION <br /> (z y,4�.f Q--r-� (For Non-Transferable, Revocable, Suspendable) <br /> --a---� 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 San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaqui Local Health District. <br /> Exact Site Address tro' 1' ° <br /> City/Town _ <br /> Owner's Name `` t Phone <br /> Address / r City r e <br /> Contractor's Name .-.,ay License# "7`� Business Phone _ 11 <br /> Contractor's Address "` 11�' L <br /> - Emergency Phone.. <br /> Is Certificate of Workman's Compensation Insurance on File With, JLHD? Yes-,>C— No <br /> TYPE OF WORK (CHECK): ._ NEW WELL❑ DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM T <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines f 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-off Well Casing <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN " - Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION : ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL r El OTHER Other Information <br /> � GEOPHYSICAL .. � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> e Type of Pump `"� H.P. - 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: state Work Done /a Lalb d <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 /> Homeowner 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 for which this i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspectio for o routi and final inspection. $ <br /> Signed X <br /> Me: Date: <br /> (Draw Plot ion on Reverse Side) <br /> i <br /> FDR DEPARTMENT USE ONLY —r <br /> PHASE <br /> Application Accepted By ��— Date���S <br /> Additional Comments: <br /> Phase 11 Grout Inspection _ - <br /> P ase ill Fin i Inspection _ <br /> Inspection By Date Inspection By Date ly—�� �G i <br /> { <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT E- ❑ PER SITE - ❑ EACH -.❑ Januar <br /> y 1- <br /> ceived-By January 31. ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ VDUEHE <br /> DATE :DATE REMITTED -AMOU -' <br /> FEE ys 'LESS <br /> '�k <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r - <br /> .k ] 3S <br /> Received by Date ��. O� �� Y <br /> Receipt No., Permit No. Issuance_D_te Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201` <br />