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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 madeto the San Joaquin Local Health District fora permit to constructand/or installthe work herein described.This application is <br /> made In compliance with San Joaquin County Ordinance No. 1882 and the.rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Owner's Name 6 ' - Phone "" <br /> Address City <br /> Contractor's Name ' License#?�/��� - Business Phone <br /> Contractor's Address ��� �-Ir ��fly _ 'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No ` <br /> TYPE OF WORK.(CHECK)--" —NEW WELL%t DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ ) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ F <br /> DISTANCE TO NEAREST: Septic Tank 00F77_ Sewer Lines Pit Privy v ' <br /> Sewage Disposal Field_ Cesspool/Seepage Pit Other <br /> Property Line sQA rivate Domestic Well Public Domestic Well <br /> INTENDED USETYPE OF WELL r� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation <br /> °.DOMESTIC/PRIVATE <br /> 11 'DRILLED Dia. of Well Casing _ I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d- <br /> ❑ IRRIGATION 'R'GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION CU ROTARY Type of Grout <br /> ❑ DISPOSAL ❑'OTHER Other Information <br /> 13 GEOPHYSICAL z Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> .c <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure', m <br /> 1 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. t <br /> Home owner or licensed agent's signature certifies the follow€ng:"1 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." <Z,4 <br /> I will call for WGrout Inspection prior to grouting and-a final inspection. <br /> Signed X Title: <br /> Date: <br /> t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENTUSE ONLY <br /> PHASEI // <br /> � d b � Date <br /> Application Accepted By <br /> -Y <br /> Additional Comments. € <br /> Ph ue Grout Inspection Phase III Final Inspection <br /> Inspection By Date r Inspection By Date <br /> � <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 &Received'Ry January 31 C) July 1 &Received By July 31 <br /> REMITj; <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> 7 <br /> FEE <br /> LESS <br /> !( <br /> PRORATION f1 <br /> e - <br /> PLUS <br /> PENALTY - <br /> OTHER ry <br /> OTHER <br /> Received by Date Receipt No. Y Permit No.. Issuance.[Date <br /> - -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON;AVE.,P.O.Box 2009 STOCKTON,CA 95201 �' <br />