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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, i <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL �� e <br /> ENVIRONMENTAL HEALTH PERMIT ] <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the Sa oaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui County Ordinance.N . 1862 and th rules and regulations of the San a uin 4ocel Health District. <br /> Exact Site Address City/Town <br /> '/ <br /> Owner's Name + Phone 79)�' F <br /> Ad d ress City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone 414-4 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes.._.._ No r <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL�f� <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 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 Surt eal Installed y: <br /> PUMP INSTALLATION: Contractor Gj <br /> Type of Pump }{p <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 —D <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 icensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is i ued, I shall of employ any person in such manner as to become subject to workman's compensation laws of California." <br /> ontractor's hiri or sub-contras sign a ertifies the following:"I certify that in the performance of the work forwhich this <br /> permit i ssue I aN empl ub' t to workman's compensation laws of California." <br /> I will c r a out Ins p ti t routs nd a final inspectio <br /> Signed Title: Date• <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE II Q/ <br /> Application Accepted By • �� Date9 / <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a a III Final Inspection <br /> Inspection By Date Inspection By ;w• Date l Z C) <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE c <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 'S <br /> Received by Date Receipt No. Permit No. fssuarke D e Mailed Deiivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />