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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 Nan-Transferable, Revocable, Suspendable) /, PUMP&WELL <br /> ENVIRONMENTAL HEALTH°PERMIT l/ <br /> (COMPLETE IN TRIPLICATE) WATER_QUALITY <br /> r� <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 with San Joaquin County Ordinance No. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> r II�' <br /> Exact Site Address �` 4 . 7 t City/Town ' <br /> Owner's Namev Phone: ..' <br /> - � <br /> Address ACity <br /> Contractor's Name License#177 lD Business Phone <br /> Contractor's Address Emergency Phone S� 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ V <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> 4 INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 /3 �} <br /> PUMP REPAIR: ❑ State Work Done 1 <br /> DESTRUCTION OF WELL: Well Diameter J Approximate•Depth <br /> Describe 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 <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 for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title:.-1 �, Date: <br /> (Draw Plot Plan on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection h it al 1 pection n r <br /> Inspection By Date Inspection B Date v v <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 '❑ July t &Received By July 31 <br /> BILLING REMITTANCE $ <br /> a` BASE EXPLANATION DATE DATE REMITTED -AMOUNT DUE CREMIT <br /> HECKED <br /> AMOUNT <br /> FEE' S . �? <br /> ? LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �er-rs <br /> Received by Date Receipt No. Permit No. Issua ce Daii Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />