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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) J PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local H9alth District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance N , 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /� fhb t 1iL [U City/town _ <br /> Owner's Name i '°' Phone <br /> Address _- LJ e;�L� - City <br /> Contractor's Name License#1` -^�.�5 �a/ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's ompensation Insurance on Fit With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ - DEEPEN ❑- RECONDITION❑ - DESTRUCTIOW---- PUMP <br /> -N❑� - <br /> WELL CHLORINATION IJ WELL ABANDONMENT 11 OTHER 13 PUMP INSTALLATION W--- 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 /> ❑ IN USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> JQ'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 PumpH.P._T_� <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. <br /> Home owner or licensed agent's signature certifies the following-"I certify that in the performance of the work forwhich this permit F <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 forwhich this r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> c or a Grout 1psgg0en prior to grouting and a final Inspection. -. <br /> r <br /> Title: ;-..t f .�C - Date: - 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��J-%/`�' <br /> Application Accepted--ByDate <br /> Additional Comments: <br /> Phase II Grout Inspectionas I F 1 Ins ection <br /> Inspection By Date Inspection By to r7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT'. ❑ PER SITE- ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE - ' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4 cf14 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 'Receipt No., ermi o. Iss ance❑ te. I Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />