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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) a` <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 w'th San Joaquin County Ordinance Nq„1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> 011111111 <br /> Owner's Name Phone �� F <br /> Address City <br /> Contractor's Name License#J Business Phone lox: n <br /> Contractor's Address � Emergency Phone <br /> � <br /> Is Certificate of Workman's Compensation fnsurance 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 REPAI& <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy n , <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 13 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 401 6f 4_4 <br /> PUMP REPAIR: ;State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appr imate Depth <br /> DLscribe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County _ f <br /> ordinances, state laws, and rules Viand 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gro insp ction prior to grouting and a final inspect' <br /> C, <br /> Signed X Title: Date <br /> r <br /> t (Draw Plot Plan on Reverse Side) <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By I! - Date 12- <br /> Additional <br /> ZAdditional Comments: <br /> Phase 11 Grout Inspection efgase III Figpi Inspection <br /> Inspection By I Date Inspection By Date <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT El PER SITE 1:1 EACH El January 1 &Received By January 31 ❑ J Received By JuVy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t <br /> " <br /> FEE 5 <br /> LESS <br /> PRORATION € <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cQ a'G <br /> Received by Date Receipt No Permit No Is ance Date Mailed Delivered <br /> . PPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ + <br />