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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&fiVELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> OMPLETE IN TRIPLICATE) <br /> (C <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with. an Joaquin County dinanc N .1862 nd the rules and regulations of the San J in Loz2llealth District., <br /> Exact Site Address City/Town J <br /> w <br /> Owner's Name Phone <br /> Address rCity �, <br /> Contractor's Name icense# Business Phone <br /> Contractor's Address _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLWD? Yes No <br /> F <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> 1' �~ Sewer Lines -1/0 <br /> �/ Pit Privy " <br /> DISTANCE TO NEAREST: Septic Tank 3 a <br /> Sewage Disposal Field �a� Cesspoo/S �qe Pit Other <br /> Property Line_Private Domestic Well Public Domestic Well �-�--- <br /> INTENDED USE TYPE OF WELL <br /> ❑ 1 LISTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> ❑/DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 5� Yr <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 95 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: iWell Diameter Approximate Depth <br /> i 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 7� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I ` <br /> Home owner 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 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:1 certify that in the performance of the work forwhich this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I=call fora Grout Ins ection nor to grouting and a final inspection. <br /> Signed X <br /> Title: A w Date: <br /> 15 <br /> (Draw Plot Plan on Reverse Side) <br /> F <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE 17 <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> M Phase II Grout InspectionPh I Final Inspection <br /> q I n <br /> Inspection By Date I Inspection B Date <br /> Ineasvrce p,f�JkAr S�a� <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 /> BASE - +EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> Ik{ LESS <br /> PRORATION {v <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> OTHER <br /> r <br /> 7 <br /> VReceived by ate - Receipt No, Permit No. - ssuance Date Mailed Delivered <br /> w APPLICANT—RETURN ALL COPIES TO:.. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bok 2009 STOCKTON,CA 95201 <br />