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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> FOR OFFICFt.USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with`San doaquin County Ordinance.-No. 1862 and th'e ules andIteglylations of the San'Joaquin Local Health District. <br /> Exact Site Address City/Town '`! <br /> Owner's Name + -•` �[ f' spy :u. f _ Phone ' * ! <br /> Address d r ��l} T}tet a_. City ';: ° <br /> Contractor's Name f License# Business Phone <br /> Contractor's Address ='� 'r�-�y : 7 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No W' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ —PUMP INSTALLATION ❑ PUMP REPAIR 13 <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 1 a 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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <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 Yft,,. d�dc r <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 for which this <br /> permit is i��e'd, I hall employ persons subject to workman's corrmperisaticiin laws of California." ; <br /> I willcall fo"r_,a Grout Inspection prior'to grouting and a final inspection. r r r <br /> Signed X ' Title: Date: <br /> l� (Draw Plot Plan on Reverse Side) —�•� <br /> O,R`DEPAMENT U E ONLY f <br /> PHASE I ' r'{ 4-1 r5 <br /> Application Accepted By Date <br /> a <br /> Additional Comments: <br /> 3 <br /> Phase II Grout Inspection f Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> # S_ <br /> Fee Is Due: ❑ ANNUALLY, _ - ❑ PER UNIT- —0 PER SITE —El EACH "*�❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATI N DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1 <br /> LESS t <br /> PRORATION <br /> PLUS { <br /> PENALTY <br /> OTHER <br /> I <br /> 1 <br /> OTHER <br /> Received by bate Receipt No. Permit'No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 r <br />