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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y; <br /> FOR OFFICE USE: APPLICATION_ <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL `� t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> �1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct arid/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or inance Ido. ]862 and the rules and regal o he San Jo gain Local Health bistrict. <br /> Exact Site Address O t4i ty/Town <br /> Owner's Name ''J'4- Phone <br /> n _ <br /> Address City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address p Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes��� No d <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ $ <br /> N 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 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. 00 <br /> l0 <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 forwhich 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 /> �jI will call for a Grout spection prior to grouting and a final inspect n. <br /> ! ,/J? ice, 3 _ <br /> Signed X Title: Date: K <br /> (Draw Plot Plan on Reverse Side) ' <br />`r <br /> FOR DEPARTMENT USE ONLY <br /> l , <br /> PHASEI <br /> Application Accepted ey � Date <br /> zs1�a <br /> i Additional Comments: <br /> I Phase II Grout Inspection Phase III Final Inspection t <br /> Inspection By Date 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 /> + REMIT I <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATuDN <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No, Issuance Date Mailed. _Del i0bred <br /> APPLICANT—RETURN-ALL COPIES TO NVIRONMENTAL HEALTH PERMITISERVICES ilii�1601 E.HAZELTON.AVE.,P.O.Box 2009 STOCKTOH,CA 95201 .� <br />