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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR Of' ICE USE: APPLICATION y <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 1/' PUMP&WELL <br /> `' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .WATER QUALITY I <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 Joa ujD G,unt rdinanc No. t 62 nd the rules' nd regulations of the San Joaquin Local Health District. r <br /> Exact Site Address -� City/Town If <br /> Owner's Name to2z <br /> Phone <br /> Address ' City ` <br /> Contractor's Name j�. License# Business _hone _ ^ J <br /> Contractor's Address .- Emergency Phone _'? _J <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes /,( No <br /> TYPE OF WORK (CHECK): NEW WELL0 DEEPEN El RECONDITION 13 DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI9 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank I Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lined Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> ❑a,INDUSTRIAL I] CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION <br /> GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL L I OTHER Other Information <br /> ❑ GEOPHYSICAL I' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done R <br /> PUMP REPAIR: State Work Done ° f <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 /> i� ordinances, state laws, and rules and regulations of the Sart 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." i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> I will call for a Grout Inspectiontpno to grouting and a final inspe ' <br /> Signed X `� Title: bate: <br /> (Draw Plot Plan on Reverse Side) <br /> E FOR DEPARTMENT USE ONLY <br /> i PHASE <br /> Date <br /> Application Accepted By <br /> i <br /> Additional Comments: <br /> Phase II Grout Inspection a i. nal Inspection <br /> Inspection By Date 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 /> REMIT <br /> - BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUF CHECKED <br /> t1 DATE DATE REMITTED AMOUNT <br /> t <br /> FEE <br /> LESS I <br /> PRORATION r <br /> PLUS k <br /> PENALTY <br /> OTHER F <br /> OTHER + <br /> Received by Date 11 Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: [ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2004 STOCKTON,CA'9520 - <br />