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T� fApplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FO.Ft ICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) 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 an install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaytgin Local Health District. <br /> j l�� <br /> Exactr5ite Address City/Town <br /> Owner's Name . Phone <br /> i <br /> Address --�;5� > City h <br /> Contractor's Name License Business Phone <br /> Contractor's Address ��� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ._ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank i Sewer Lines ,��.. � Pit Privy <br /> Sewage Disposal FiIId Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well ; <br /> INTENDED USE TYPE OF WELL12 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> (1 <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 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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, V' <br /> Home owner or licensed agent's signature certities 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 far which this <br /> permit is issued, I shall employ persons subject to wo kman's compensation laws of California." <br /> I a rout Ir4ection r t routi d a final inspection. <br /> Signed X t <br /> Title: Date: <br />` ` <br /> e <br /> (Dr,w Plot Plan on Revers ide) <br /> p FOR DEPARTMENT USE ONLY p <br /> PHASE 1 ®ii _ 4'(� <br /> Application Accepted Byj/13 © Date <br /> t Additional Comments: <br /> hase 11 Grout Inspection Phase til f=inal Inspection <br /> r <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY :m <br /> r <br /> OTHER <br /> OTHER { <br /> Received by Date Receipt No. Permit No 4ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />