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r;= -:�• ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICF.USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) / <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) " ATER QUALITY <br /> Y 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 <br /> made in compliance with San Joaa'ug�in County Ordinance No. 1862 and the r les a dreg fations of the San Joa Local Health District. <br /> Exact Site Address �-�KaJ1 f�.' f-. / as7ity/Town t- <br /> Owner's Name Phone J <br /> Address City` <br /> f Contractor's Name d License Business Phone <br /> Contractor's Address Emergency Phone d <br /> Is Certificate of Workman's Com pensatiori'Insurance on File With SJLHD? Ye?- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ - DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> i Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casingd <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ <br /> 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 DoneF <br /> f <br /> DESTRUCTION OF WELL: Well Diameter 011 <br /> 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit C <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation-laws of California." 'f <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that ih the performance of the work for which this 4 <br /> permit is issued, I shall employ persons subject to workman's compensation-laws of California." 0 <br /> y <br /> I will call for a Grouhlnspection prior to grouting and a final inspection. — tt <br /> .7 <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> »4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> Application Accepted BYDate <br /> Additional Comments: �) <br /> Phase 11 Grout Inspection ase III Fin nspectio <br /> Inspection By Date Inspection By ate _ ��� �f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jarwary 31 ❑ July 1 &Received By July 31 <br /> 11 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE PATE REMITTED AMOUNT DUE CHECKED i <br /> AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY l <br /> OTHER 1 <br /> Y E <br /> OTHER 14 <br /> D 3 - T k <br /> Received by :� Date Receipt No. Permit No. lssua ce Date Mailed Delivered F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />