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ApplicationsWill BeProcessed.When Submitted Properly Completed. Be Sure To Sign The Application-. <br /> FOR USE: LI APPLICATION .. <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT C <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY C <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 application isCP <br /> # made in compliance with San Joaquin County 0 di a o. 1862 and the rules and <br /> ulations of the San Joaqui ocal Health District, <br /> Exact Site Address Q City/Town r <br /> L <br /> Owner's Name li ' Phoney <br /> Address City <br /> Contractor's Name 'I' License#_ e � Business Phone <br /> 4 Contractor's Address �F 7 <br /> Emergency Phone <br /> s Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WI ELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI5AT" <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> l Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing a <br /> ❑ DRIVEN <br /> 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: �:F <br /> PUMP INSTALLATION: <br /> II. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 1 <br /> j PUMP REPAIR: ,State Work Done ° I <br /> DESTRUCTION OF WELL: - Well Diameter pproximate Depth <br /> Describe Material and Procedure k <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 orlicensed'!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," <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ,I <br /> Wil call for a Grout I l pection prior 10 grouting and a final inspection. <br /> f <br /> 4 Signed X s Title: <br /> i� (Draw Plot Plan on Reverse Side) Date: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By JA Date <br /> Additional Comments: ll <br /> !r <br /> Phase.sll Grout Inspection Phas f Final Inspection 1— G <br /> Inspection By .j DateJ `U� <br /> Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 , <br /> BILLING REMITTANCE $ REMIT <br /> BASE I EXPLANATION DATE AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE If y <br /> LESS !M _ � <br /> PRORATION14 f <br /> PLUS ,If <br /> PENALTY L s <br /> t <br /> OTHER <br /> OTHER �f <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICESL 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />