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applicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE iN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance ap oaqu n ounty Or inance No. 1862 and the rules and regulations of the San Jo quin L c ealth District. <br /> Exact Site Address �i City/Town �,�IV G�!'L <br /> Owner's Na �C� r Phone <br /> Address City <br /> Contractor's Name r� License Business Phone z V <br /> Contractor's Address G 1 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION* PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line-Zo Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> 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 /> to- <br /> 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout 9P G / ,C <br /> ❑ DISPOSAL ❑ OTHER Other Information Q <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor d <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Q.. <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 /> I will call fora rout Inspe tion prior to grouting and a final inspection. <br /> Signed XU <br /> Title: Date: ` <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMEN USE ONLY <br /> PHASE I �+ <br /> Application Accepted By bate 0 Q <br /> Additional Comments: <br /> hase II Grout Inspection Phase III Final Inspection <br /> Inspection By " lSate 6=,�6-?o Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &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 ✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No lissuarfice Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />