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* - pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> yo 14-e d (For Non-Transferable, Revocable,{i Suspendable) PUMP&WELL <br /> �- ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reg lations of the San Joaquin Local Hpalt♦District. <br /> Exact Site Address <br /> ` City/Town SQ <br /> Owner's Name <br /> I A Al d Phone", Q <br /> Address <br /> Contractor's Name License# Business Phone F' <br /> Contractor's Address r ,t. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ElRECONDITION 13 DESTRUCTION❑ y, <br /> Pi J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER C1PUMP INSTALLATION* REPAIR .y <br /> REPLACEMENTI� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines t 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 1 H.P. <br /> PUMP REPLACEMENT: .� State Work DoneLtl Q Ausr1T� <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 /> Home owner or licensed agent's signature certifies the following:"1 cerfify 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I will call for a Grout Inspection prior to grouting and a final inspection. w <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ' 4 <br /> PHASE I Date <br /> Application Accepted By . <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <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 &ReceivedRTuly 31 <br /> EMI <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> < DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cc v by Date Receipt No. Permit No. Issuance Date MaileDelivered <br /> AP ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 09 STOCKTON,CA 952011 <br />