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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQR oFF�cs= USE: APPLICATION <br /> i <br /> . (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' <br /> (COMPLETE IN TRIPLICATE):�f'[b':: �, MC►¢�r�OS*-- TEiR QUALITY �-£OdLJr f�� " Z2-"o—!� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install tie work herein described.rt This application is <br /> a made in compliance with San Jo qui Cou ty Or ' e No. 862 and the rules and regulations of the San Jo uin Lo al Health District. <br /> Exact Site Address City/Town <br /> Owner's Name or Phone <br /> Address City - `1 <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phor r �} <br /> Is Certificate of Workman's Compensation nsurance o File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLQV1 DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAREST: Septic Tankt5 - A/, 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 WELLJ r� y� T <br /> ❑ INDUSTRIAL /C;t $ <br /> CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 4 <br /> C3 GEOPHYSICAL Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: ❑ State Work Done I <br /> PUMP REPAIR: a ❑ State Work Done li <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> Ib � <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. - li <br /> Homeowner or licensed agent's signature certifies the following:"I certity 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 certifles the following:"I certify that in the performance of the work fo rwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation lavas of California." �; r <br /> I 'II call for a Gr nspection r to grouting and a final insp tion. !� <br /> Signed X Title: Date: t I� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> `-'" ` © Date. �. <br /> Application Accepted By _ <br /> Additional Comments: <br /> Phase II Grout Inspection 41 Phase JII Final Inspection <br /> Inspection By. Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &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 /> FEE (� a <br /> LESS 7 /✓gyp f��t4t <br /> PRORATION <br /> PLUS y <br /> PENALTY /V4? _.IA/�'V,E C I�� <br /> OTHER <br /> lowOTHER <br /> J14 <br /> eceived by Dald Receipt No. Permit No. Issuance Date MailedDelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br />