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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 r , _ <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/orinstall the work herein described.Thisapplication is <br /> made in compliance with San Joaquin County Ordi nce No.18"ande rules and regulations of the San J aquin Local Health District. <br /> �1� .. <br />` Exact Site Address Cj n. r City/Town f� <br /> Owner's Name Phone <br /> Address City ` 1 <br /> Contractor's Name " License# Business Phone''= �5 <br /> IPJ °%jib , s`. `Fr':• Emer enc <br /> Contractor's Address g y Phone <br /> r_ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ut <br /> TYPE OF WORK (CHECK):­_.;T NEW WELL❑ DEEPEN ❑' RECOND1710N0DESTRUCTION❑ <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAt_ ❑ 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 />( ❑ OTHER Other Information <br /> I ❑ DISPOSAL C� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: . (w, <br /> PUMP INSTALLATION: 1 Contractor —'��! �}� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: ; Well Diameter Approximate Depth <br /> k Describe Material and Procedure <br /> f 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 /> _ h <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 /> F 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 /> t <br /> I will c f r a Geo Inspection prior to grouting and a final inspection. Date: / <br /> ` D# t ! T <br /> Signed X - - -. Title: - <br /> (Draw Plot Plan on everse Side) <br /> a # FOR DEPARTMENT USE ONLY <br /> + PHASE <br /> Application Accepted By Date <br /> Additiorial Comments: } <br /> r Phase II Grout Inspection h II 'nal Inspection <br /> f Inspection By # Date Inspection.By Date . <br /> Fee Is Due: ❑ ANNUALLY E] PER UNIT' ❑ PER SITE "❑ EACH'i ❑ January 1 &'Received By January 31 ❑ July 1 &Received By Ju y 31' <br /> REMIT <br /> -BILLING _ -REMITTANCE - $ <br /> ' r BASE" , EXPLANATION AMQUNTDUE CHECKED <br /> DATE ? DATE REMITTED AMOUNT <br /> FEE - - <br /> LESS - - <br /> PRORATION <br /> I PLUS <br /> PENALTY- s <br /> OTHER t <br /> iOTHER '+ - <br /> r <br /> # 1 Off• r 1 1 . <br /> Received by — Date Receipt No. -- Permit No. I suanc Date- Mailed' Delivered <br /> -1— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />