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Applicatlons Will Be Processed When Submitted Properly Completed.Be Sure To Slgn The Application. <br /> FOR OFFICE USE: APPLICATION h��� -2— <br /> [For Hon-Transferable, Revocable,Suspendabley PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT •- ��� ` � <br /> WATER QUALITY <br /> [COMPLETE IN TRIPLICATE] r•f r ��,; , Xr, r ,-�. ►_ <br /> istrict far a permit to construct and/or install the work herein described.This application is- <br /> Application is hereby made to the San Joaquin Local Health D made in compliance w' h San Joaquin County Ordigance Na.1862 and the.rules and regulations of the San - aquin Local Health District.. . <br /> Exact Site Address _] City/7own — dr <br /> K <br /> zy: Phone;Owner's Name <br /> City— — ! <br /> Address j <br /> L'•, License# Business Phon <br /> Contractor's Name <br /> Contractor's Address �� <br /> Emergency Phone'' <br /> Is Certificate of Workman's ompensation Insurance on File With_SJLHD? Yes No <br /> TYPE OF WORK (CHECK) NEW WELL❑ DEEPEN❑ RECONDITION DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ I OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> C <br /> REPLACEMENT❑ 1 <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 /> fl I_W6STRIAL ❑ CABLE TOOL Dia. of Well Excavation . <br /> 93/❑OMESTIC/PRIVATE ❑ DRILLEO Dia.of Well Casing <br /> ❑ DOMESTICIPli ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SurTace Seal Installed By.- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P t�] <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 <br /> t 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. <br /> Home owner air 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 a sub-contracting signature certilies the following:"l 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 II Jor a Grout Inspection prior to grouting and a final inspection:-; <br /> c g. <br /> Signed x <br /> Title: Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE l Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase If Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By—_ Date - <br /> Fee Is Due: ❑ ANNUALLY ❑ PFR UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 R i January 31 ❑ July 1 &Received By July 31 <br /> .. REMIT <br /> - flASE- ExPL'ANATION FILLING REMITTANCE S AARDUNr DUE CHECKED <br /> i DATE [SATE REMITTED AMOUNT <br /> FEE C <br /> LESS <br /> PRORATION f - <br /> ., c <br /> PLUS - <br /> PENALTY $ t _ <br /> t- <br /> OTHER r <br /> UTHEH - - - <br /> Received•by Date Rece+p!No. - - Permit No - usn" ale Maifod DeliverBd - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAVLTON AVE..P.O.Boa 2009 STOCKTON.CA 95201 <br /> t4 <br />