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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) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is <br /> made in compliance with SJoaquin County Ordinal No. 1852 and the rules and regulations of the San doaquin Local Health District. <br /> Exact Site Address Qom- City/Towne? <br /> Owner's Name L� Phone <br /> Address City <br /> Contractor's Name License S& Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR Er <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 /> INTENDED 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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor k _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i <br /> PUMP REPAIR: -State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Ap roxinl D pth <br /> 1 <br /> Describe Material and Procedure 1 <br /> a <br /> I 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 /> l wilt Il forut Inspection prior to grouting and a final inspe¢1f61j <br /> Signed X r7, Title: � 1�4 Date: - <br /> (Draw Plot Plan on Rev-erse Side) p <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A�cnr <br /> Application Accepted By <br /> 1 Date <br /> Additional Comments: <br /> Phase It Grout Inspection hase III Final Inspection i <br /> Inspection By Date In By ate <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January I &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 /> FEE a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> Received by Date .. �Receipt No. Permit No. Iss artce Date Mailed Delivered <br /> APPLICANT-Fi9fiRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />