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y Applications Will Be Processed When Submitted Properly Completed. Be Sure To SigM �HApp cU 4�nf t ' <br /> FOR OFFICE USE: APPLICATION .J I'll- <br /> �,�� <br /> �� (For Non-Transterable,Revocable,Suspendable) PUMP{&vuIk;i, 1 t <br /> �A pl �N py��R.0 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 11 <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstall the work herein described.Thisapplication is <br /> made in compliance with San Joaq i County Ord' ante N 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> 1 DA,e IZ— City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name ^ <br /> City <br /> Address <br /> Contractor's Name License# • �� eu iness Phone <br /> Emergency Phone he <br /> Contractor's AddressNo <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ I <br /> REPLACEMENT Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Cess ool/Seepage Pit Other <br /> - - -- Sewage Disposal Field p <br /> Property Line iPrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> P? 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 /> Well Diameter <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I her certify that-1 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 or licensed agent's signature certifies the following:1 certify that in the performanceof thework forwhich this permit b <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.". <br /> ' <br /> A,,,,Or,,,Grout I �ecllon�rior o grouti�iandda final inspection Title:Signed X (Draw PlotPlan on Reverse Si(Te) <br /> FOR DEPARTMENT USE ONLY ��w <br /> PHASE I Date <br /> 1 Application Accepted B <br /> Additional Comments: anal Inspection <br /> I <br /> Phase II Grout Inspection Date <br /> Inspection By <br /> Date . Inspection <br /> ❑ UNIT ❑ PER SITE ❑ EACH E3 January 1 eceived;By January 31 ❑ July 1 &Received EMITBy uly 31 <br /> Fee Is DUB: E3 ANNUALLY PER <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> f PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> I Received by <br /> ate eceipt No. Permit No. Y Issuanc Date , Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />