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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _FQR QfFICE USE: APPLICATION A <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP& ELL a <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is Y. <br /> F 'made in compliance with San Joaquin County Ordina ce No. 1862 and the rules and regulations of the San Joaqui ocal Health District. 1 <br /> Exact Site Address City/Town I <br /> 9r r <br /> Owner's Name Phone <br /> Address City e <br /> Contractor's Name License ff ��7{T'j Business Phone_,_ f <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No f +' <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ - DESTRUCTIONN, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Priv f <br /> Y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other " <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 7. <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 <br /> PUMP REPAIR: ❑sState Work Done <br /> 9 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure .. <br /> f <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." i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this t <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I �caWl ,#Iqpflnspectlon pt rior to grouting and a final inspection. <br /> Signed X TItle: olDate: <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> o <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection �{ <br /> Inspection By Date Inspection By Date <br /> Fee IS:DUE: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE E] EACH C1 January 1 &Received By January 31 EJ July 7 &Received By July 37 <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION DATE DATE .REMITTED AMOUNT DUE CHECKED' 'u <br /> AMOUNT <br /> FEE <br /> LESS 'T. <br /> PRORATION r <br /> PLUS <br /> PENALTY � <br /> `a• <br /> OTHER <br /> OTHER <br /> a I' <br /> Received by Date Receipt No, Permit No- Issuance Date Mailed Delivered 71 <br /> APPLICANT,RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boa 2009- STOCKTON,CA 95201 <br />