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Applications Will Be Processed When Submitted Properly Completed. Be Sure To ign The Application. 1 <br /> FOR OFME USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL l/ <br /> ENVIRONMENTAL HEALTH PERM <br /> (COMPLETE IN TRIPLICATE) WAITER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with.San Jo Cf ty ina a No. 186 n the rules and regulations of the San uin cal Health DDiiwrict. <br /> Exact Site Address.. y City/Town <br /> Owner's Name Phone <br /> Address "+ City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address tt Ernergeney Phone j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):" NEW WELL-0 DEEPEND--" RECONDITION❑ DESTRUCTION❑— <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ® ' PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> v <br /> r Sewage Disposal F' 1d Cesspool/Seepage Pit Other <br /> +� Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 0 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> XDOMESTIC/PRIVATE ❑ DRILLED ',... Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r� R. <br /> ❑ IRRIGATION ❑ GRAVEL PACK. Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ 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 /> 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 /> 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 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:'9 certify that i,n 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 c II for a Grout In ction pri r to grouting and a final inspection. <br /> Signed X - Title: Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> AHAS ation Accepted B Date a i <br /> PP P !! i <br /> Additional Comments: +� fl2�►ih � - <br /> Phase II Grout inspection PhaseI Final Inspection <br /> Inspection By Date Inspection By bate <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J9Vary 31 ' ❑ July i &Received By Juky 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION -� AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT 1 <br /> FEE 4.�5�' <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> M <br /> OTHER <br /> OTHER <br /> -Received by .. Date -Receipt No. -.Permit No. Issuance.Dale Mailed Delivered � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 ' <br />