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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 fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Or inance No. 1.862 and 1he rand a ulations of the Sa Joaq c H alth District. <br /> Exact Site Address a I City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name ool License# Business Phone <br /> Contractor's Address Emergency Phone� <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No vA <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ i <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 /> ❑ INDUST_A 1 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 1:1 DRILLED 'N Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC: �❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N' <br /> ❑ DISPOSAL z ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL { Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter pproximatg Depth <br /> i Describe Material and Procedure O <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 ru'les.and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's si nature certifies the followin "Lcertif that in the performance of the work forwhich this permit <br /> f <br /> 9 9. _ �9�t Y P P i <br /> is issued, I shall not employ}any person in such=manner as to become subject to workman's compensation laws of California." <br /> t Contrractor's'hiring`,or sub-contracting signature certifies thfollowing:"Icertify that in the performance of the work forwhich this <br /> 4 `5sues... <br /> per.�tt is 1d'"I°shall employ persons subject to workman's compensation laws of California." � <br /> I will call for a Grout ins ection r 1 in and a final inspect'O <br /> Signed X € Title: ./ Date: 3 / Q <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY' <br /> PHASE I <br /> Application Accepted By -�^^( _— !"—' -- Date 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE. ❑ IiACH El January 1 &Received By January 31 El July l &Received By July 31 <br /> h--"' -' REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED- <br /> .t DATE DATE REMITTED AMOUNT <br /> FEE *13 s o qka <br /> LESS <br /> PRORATION <br /> PLUS 1144t J1 11 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> eceived by Lraie L. Receipt No. Permit NO. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES- - 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />