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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _I <br /> FOR OFFICE USE: APPLICATION of <br /> (For Non-Transferable, Revocable, Suspendable) S <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r <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 a d the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address aAle, City/Town <br /> r <br /> Owner's Name LPhone <br /> Address City <br /> Contractor's Name c r icense# 9Z/ 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❑ �I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El <br /> REPLACEMENT❑ 64 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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. 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 11 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 <br /> I <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 /> Home owner or licensed agent's signature certifies the fallowing:"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 lnspectio�xrior to grouting and a final inspection. q c� <br /> Signed X Title: /T' Date: <br /> (Draw Plot Plan on Reverse Side) <br /> h <br /> FOR DEPARTMENT USE ONLY <br /> 4 PHASEI <br /> Application Accepted By Date <br /> a 9 <br /> Additional Comments: <br /> Phase II Grout Inspection Ph III Final Inspection <br /> Inspection By Date Inspection By at o� <br /> E Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ J I Received By July 31 <br /> BILLING REMITTANCE $ - REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> I lFFEE ��. D O 4, <br /> f LESS <br /> Ii PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> y-11:7s0 1 Cls 7/ <br /> Received by Date Receipt No. Permit No. Issuance 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 />