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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 ttje.rules and regulations.of the 5a_04oaquih Local Health District. <br /> Exact Site Address -5 City/Town t <br /> Owner's Name lei . t:��. � ( en a Phone <br /> Address ��- rCt "' City <br /> Contractor's Name � - _ Llcertse t€ L business {'hone <br /> Contractor's Address TAY Emergency Phone i <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes C.� No <br /> TYPE OF WORK(CHECK): NEW WELL 0— DEEPEN ❑ RECONDITION❑ DESTRUCTIO�N.O <br /> WELL CHLORINATION El WELL,ABANDONMENT 13OTHER ❑ PUMP INSTALLATION . PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f <br /> i� Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 1 TYPE OF WELL <br /> 11�INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ,�, <br /> I�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 Se I 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 /> 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 forwhich this <br /> permit is issued, I shall employ'persons subject to workman's compensation laws of California." <br /> ri <br /> I wi11 call for4 Grout Ins ction prior to grouting and a final inspection. <br /> .1 <br /> Signed Title: Date: <br /> I (Draw Plot Plan on Rev rse Side) <br /> FOR DEPARTMENT USE ONLY e <br /> PHASE I <br />�. Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectionh 4e 11 nal Inspection <br /> Inspection By Date Inspectio&By .+ Date <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - C1 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> Lf, DATE DATE REMITTED AMOUNT <br /> rqFEE <br /> t <br /> F LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> { <br /> OTHER o <br /> - Received by Date Receipt NO.' Permit No ssuan a 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 />