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Applications Will Be Processed When Submitted Properly Completed:Be Sure*rwo.y.. �� <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable,Suspendable) i <br /> - PUMP&WI=LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ` WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described"This application is ! <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San aquin Local He h District. <br />:. Exact Site Address © City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# 02 Business Phone l <br /> Contractor's Address Emergency Phone C2 J-3 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION 13DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ i <br /> REPLACEMENT❑ <br /> I 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 y' <br /> 4 <br /> INTENDED USE 1 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED } <br /> r Dia. of Well Casing <br /> ❑`DOMESTIC/PUBLIC ❑ DRIVEN Gauge'of Casing <br /> ❑ IRRIGATION,_•__, w .._ .,.., _ _ j0_GRAVEL"PACK._, Depth.of.Grout Seal - -- - <br /> ❑ CATHODIC PROTECTION © ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br />'i ❑ GEOPHYSICAL tf ce Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum H.P. <br /> 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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I 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 /> v X l iJ �1�.�K1l�ifr .y - Title: Date: RIO— <br /> Signed <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY } <br /> .PHASE 1 �/., q ..q, <br /> Application Accepted By V"� Datela t� <br /> Additional.Comments:.. �- ..: .. -- +-- ..r ..>�•a - f <br /> Phase 11 Grout Inspection III Final Inspection <br /> Inspection By 04�Date <br /> Inspection By Date <br /> + Fee Is Due: ❑ ANNUALLY ❑ PER UNIT.— ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $ Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ' -BASE EXPLANATION AMOUNT DUE,' CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> q O <br /> FEE <br /> LESS <br /> PRORATION <br /> .,,:PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 3 � <br /> Received byDate 'Receipt No. Permit No Iss ante Dat Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERV10ES 1001 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />