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FOR OFFICE.USE: APPLICATION <br /> n(For Non-Transferable, Revocable,Suspendab( # <br /> ENVIRONMENTAL HEALTH PERMIT � PLr01- <br /> WELL <br /> pftlh <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This applica ion is <br /> made in compliance with San.Joaquin C ty O dinance No. 1 62 d the rulgs and regulations of the San Joaquin Local He lth District. <br /> Exact Site Address u City/Town <br /> i <br /> Owner's Name Phone <br /> Address ` City <br /> Contractor's Name License#� si e s Phone <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensati Insurance an File With SJLHD? Yes f No <br /> TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT Q- <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 1 TYPE OF WELL <br /> ❑ IlyMUSTRIAL ❑ 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 I Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> a <br /> Ty�p"f Pump H.P. _ 4✓12 <br /> PUMP REPLACEMENT: 1r 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 /> t <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, 1 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 /> I will for a Grout Insp Mpriorto gr uting and a final inspec ' <br /> Signed X Ti___: I /1�17/.!� Date: �d <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date���`�O~w <br /> Additional Comments: <br /> Phase II Grout Inspection a III Final Inspection <br /> `< �1 <br /> Inspection By_ A )C% Date Inspection By '" Date 11l�7—LY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASF EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> �S °a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER F <br /> Received by Date Receipt No. Permit No. Iss t ance,qate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVECES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />