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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r x (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby de tothe3 Joaq u i n Loca I Hea It h D i stri ct fo r a permi t to co nst ruct and/o r i nstal I t he work h ere i n descri bed.Th is app lication is <br /> made in compliance tr „County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address - <br /> City_ —ft_e9 <br /> Contractor's Name License# �- Business Phone_%7 . <br /> Contractor's Address Emergency Phone Im <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ j f <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines Pit Privy <br /> Sewage Disposal Field I-.� Cesspool/Seepage Pit Other �- 6 <br /> Property Line,- _ Private Domestic Well ;?Q — Public Domestic Well -r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout .� <br /> ❑ DISPOSAL ❑ OTHER Other Information —�--•- <br /> ❑ GEOPHYSICAL Surface Seal Installed 8y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.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 (n <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 /> 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 torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I II call for rout spec 'on for to grouting and a final inspection. ' <br /> Signe Title: LA/ f <br /> Date: <br /> (Draw Plot Plan on Rever Side) <br /> FOR EPARTM T USE ONLY <br /> PHASE I <br /> Application Accepted By "'t Date <br /> Additional Comments: <br /> Phase II Grout inspection P se ill Final Inspection <br /> Inspection By Date Inspection B Date �`� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BELLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � �3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. IsAuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Ban 2009 STOCKTON,CA 9520�� <br />