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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION J /, <br /> (for Non-Transferable, Revocable, Suspendable) 1 7/ <br /> I ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPUTE IN TRIPLICATE) p3 "2iONATER QUALITY <br /> Application rs hereby made to the San Joaquin Loca!Health-Dlstrict for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San:)'oaquin" 'unty"or mance No.'16.62 and the rules and regulations of the San Joaquin Local Health DIs ict. <br /> Exact Site Address :.0 �! iGt/"` City/Town�_ 5 <br /> Owner's NamePhone <br /> Address e�839 ,I City Q <br />' Contractor's Name License# PP& Business Phone <br /> P Contractor's Address 7 '� Emergency Phone . <br /> k � <br /> Is Certificate of Workman's Compensationansurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITION❑ DESTRUCTION E] 6` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <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 Dim.,-of Well Excavation <br /> X DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing /� Pl/ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Qy W <br /> k ❑ IRRIGATION '�Z"GRAVEL PACK Depth of Grout Seal Q <br /> ❑ CATHODIC PROTECTION 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"cal Health District. <br /> Home owner or licensed agent's signature certifies the following:"I ce�.fify 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 ca for a Grout Inspe tion r to grouting nd a final inspection. <br /> Signed X 4 Title: Date: 4 <br /> (Draw P. Plan on Reverse tide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> _ <br /> Additional Comments: Date <br /> rout Inspection Phase III Final Inspection <br /> Inspection By GDate OY./2, <br /> Inspection By Date <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 PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE f 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY x <br /> OTHER <br /> OTHER - - - <br /> Received by Date Receipt No l] Permit No. Issuance Date - Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520& t <br />