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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) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> t Application is hereby made to theSan Joaquin Local Health District for a permit toconstruct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> Exact Site Address �` 76Z nd 0 r,.& -:taCity/Town <br /> OIL <br /> wner's Name a Phone �� -` <br /> Address City <br /> Contractor's Name 1 License#-311 o 4 6 Business Phone <br /> Contractor's Address Emergency Phone <br /> Certificate of Workm_an's_Compensation Insurance on File With SJLHD? Yes _ No <br /> I TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT PR OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I REPLACEMENT❑ <br /> r <br /> DISTANCE TO NEAREST: Septic Tank -Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> F' 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 /> r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ! ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout !� <br /> r ❑ DISPOSAL ❑ OTHER Other Information <br /> f ❑ 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 Done <br /> ESTRUCTION OF WELL: Well Diameter 1 Approximate Depth — � <br /> t Describe Material and Procedure . <br /> I hereby certify that I have prepareJ 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 /> 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, I shalt 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 /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: mw h a.I, _ Date: :T � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I <br /> Application Accepted By _. _. Date <br /> Additional Comments: <br /> Phase tl Grout Inspection Phase III Final Inspection <br /> Inspection By Date�—((� —�^-_ Inspection By Date O <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT INPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMiT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> rr FEE <br /> LESS IV <br /> t PRORATION <br /> i PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received6y Date I Receipt No "Permil No Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1601'E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA^95201 <br />