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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppiicasion. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct 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 Local Health District, <br /> Exact Site Address���J�—ma x City/Town <br /> Owner's Name �ap' . ��u' Phone <br /> City <br /> Address '`' 1 <br /> p,� c icense#�!°e 2 g 2/ Business Phone3�°-27,$7 <br /> Contractor's Name u'°`= <br /> Contractor's Address _ Emergency Phone ��� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIO ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR4!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 ❑ DRIVEN Gauge of Casing a <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I ❑ ROTARY Type of Grout d� <br /> © DISPOSAL <br /> ❑ 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: a P State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth A <br /> Describe Material and Procedure <br /> 1 <br /> F 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 regulatioris ofthe San Joaquin Local Health District. <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:"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 will call for a Grout Inspection prior to grouting and a final inspection. .gam <br /> Title: <br /> Signed X <br /> DateZl <br /> (Draw Plot Plan an Reverse Side) <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE 1 <br /> Application Accepted By _ Date t- <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection f 8 <br /> Inspection By Date Inspection By Date l-a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received' By July 31 . <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> j FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6s�oAO <br /> Received by <br /> Date Receipt No Permit No. Issuancd Date Mailed DeOrvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />