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Applications Will Be Processed When $ubmitfed Properly Completed. Be Sure To Sign The Application. <br /> FCR OFFICE USE: ;;. APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendable) ; <br /> PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work,hereindescribed.This application is I ` <br /> made in compliance with San Joa in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Loc Health District. N t <br /> Exact Site Address City/Town DD1�_t 0Lill <br /> Owner's Name Phone <br /> Address City i <br /> Contractor's Name A License #� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ i <br /> REPLACEMENT❑ L <br /> J <br /> DISTANCE TO NEAREST: Septic Tank L' es 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 Excavatio i <br /> DOMESTIC/PRIVATE ® DRILLED Dia. of Well Casing 19 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout �P <br /> ❑ DISPOSAL ❑ OTHER Other Information di <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑' State Work Done <br /> PUMP REPAIR: ❑ State Work Done G <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:"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. <br /> Signed X 7 Title: Date: <br /> (Draw Plot Plan'on Reverse Side) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I i <br /> Application Accepted By- Date ou <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection N <br /> Inspection By Date_ -`� � 41 ka Inspection � Date* <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B nuary 31 - ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BILLING, REMITTANCE $ <br /> EASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> e AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY # <br /> OTHER <br /> OTHER <br /> Received by - Date P Receipt No. - Permit No. I suan a Date ° Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.;P.O.Box 2009: STOCKTON,CA 95201 <br />