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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The If' <br /> : r4 <br /> - FORFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 4 i <br /> ENVIRONMENTAL HEALTH PERM 42 PUMP&WELL c <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ;-49 <br /> i 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 rdlnce O. 1862 d the rules and regulations of the Sa oaq in Local Health District <br />' Exact Site Address City/Town . <br /> Owner's Nam <br /> Address Phone <br /> City <br /> Contractor's Name `.t License# J Business Phone 39,"3 <br /> Contractor's Address Emergency Phone P <br /> Is Certificate of Workman's Compensation#nsurance on File With SJLHD? Yes No I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL '4 <br /> CABLE TOOL Dia. of Well Excavation1111! ' <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> AV <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION C1 GRAVEL PACK Depth of Grout"Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout V ` <br /> El DISPOSAL" El OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: El State Work Done # <br /> PUMP REPAIR: El 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 /> 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 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 <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 Title: _ ,�- Date: �z <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> t <br /> Application Accepted By f <br /> Additional Comments: Date k <br /> Inspection By <br /> Phase 11 Grout Inspection Phasal I sectio <br /> Date_ Inspection By e I Finpat <br /> Fee Is Due: []. .ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ! M <br /> BASE EXPLANAT ON BILLING REMITTANCE $ y -- 't' REMIT <br /> DATE DATES REMITTED{ AMOUNT DUE CHECKED <br /> ,J AMOUNT <br /> FEE t� �/ 4 i 1 - �t;;� y�r <br /> LESS I <br /> PRORATION <br /> PLUS 1A fy <br /> PENALTY <br /> OTHER �1 } <br /> d � <br /> OTHER ti <br /> N h <br /> Received by Dae Receipt No. Permit No. .Issuance Date Mailed <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES1 <br /> 1601 E.HAZELTON AVE.,AYP.O.Box 2009 STOCKTON,C 95201 <br />