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T 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 6 <br /> �l <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora perm it to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules aqd.regulations.of the San Joaquin Local Health District. <br /> Exact site Address `} ' City/Town <br /> t <br /> me <br /> Owner's Na "� s r Phone <br /> Address _ w _ - City <br /> Contractor's Name =�` M. ; ' License Business Phone 4s' i <br /> Contractor's Address O A 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❑ DESTRUCTIO,�N,E]� r <br /> WELL CHLORINATION ❑. WELL ABANDONMENT 13 OTHER (] PUMP INSTALLATION � PUMP REPAIR 13 <br /> REPLACEMENT❑ - <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 /> TENDED 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 ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ... o. H.P. <br /> AJQ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that 1 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 for which this <br /> y permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> I wilt ca t r a Grout inspection prior to grouting and a final inspection. <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,,,� ,_� `D.•l��O <br /> Application Accepted ByDate <br /> Additional Comments: <br /> Phase II Grout Inspection P ase III Final Inspection <br /> Inspection By Date Inspection Date O <br /> I- Fee Is Due: ❑ ANNUALLY ❑ 'PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> #_ <br /> FEE <br /> LESS y R <br /> I PRORATION <br /> PPLUS <br /> ENALTY ' Gr3,t_AV <br /> OTHER <br /> I OTHER f/ T <br /> T Received by Date Receipt No Permit No. Tisuancle Date _Mailed Delivered., <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />