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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplicauon. <br /> FOR OFFICE USE: jJ APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY4r.a 4 <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> ttao City/Town <br /> Phone <br /> Owner's Name ! ;City <br /> Ad d ress <br /> Contractor's Name <br /> r,,w.. License# - Business Phone <br /> Contractor's Address mergency Phone <br /> o <br /> Is Certificate of Workman's Compensation Insurance on File With SJL D? Yes 6 ' <br /> TYPE OF WORK (CHECK): NEW WI=LL❑ DEEPEN © RECONDITION DESTRUCTION <br /> N❑ T <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 19 PUMP REPAIR ( _ <br /> REPLACEMENT❑ • Pit Prix �^� <br /> Sewage Disposal Field <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Cesspool/Seepage Pit Other <br /> - <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ig DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 1:1DOMESTIC/PUBLIC 11DRIVEN 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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type,of Pump H.P. <br /> PUMP REPLACEMENT: n <br /> 9S-tate Work.Done -..1 <br /> PUMP REPAIR: .. ❑ State Work Done <br /> .. <br /> DESTRUCTION OF WELL: <br /> WelDiaApproximate Depth <br /> Diameter <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 L^1� <br /> ordinances, state laws, and rules and regulatioris of the San Joaquin Local Health District. <br /> Home owneer'or I icensed-agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> I 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 /> 4f <br /> I ill call-for a Grout Ins ec n for o gro and a final inspection. <br /> { <br /> itle: Date: <br /> - P <br /> Signed ' <br /> (Draw Plot an on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I t Date <br /> i Application Accepte y <br /> Additional Comme s , <br /> Phase 11 Grout Inspection Phase IR Final tpspection <br /> Inspection By <br /> Date Inspection By G• Dfe ism <br /> r Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 ReceivedJuly 31 <br /> REMIT <br /> BILLING REMITTANCE $• AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE ,REMITTED AMOUNT <br /> y. <br /> FEE c� <br /> LESS <br /> PRORATION 7 <br /> PLUS <br /> PENALTY <br /> OTHER w <br /> OTHER <br /> LDate Receipt No. Permit No I suance ate Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCI(TON,CA 95291 <br />