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t C Applications Will Be Processed When Su6niitied Properly Completed. Be Sure To`Sign The Application. <br /> FOR OFFICE USE: / APPLICATION <br /> �pr�c�jG4il (For Non-Transferable,Revocable, Suspendable) <br /> Y PUMP&WELL <br /> _ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPL TE N 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 Joaquin County Ordinal No. 1 an he rules and regulations of the San Jo�ui cal Health District. <br /> Exact Site Address City/Town <br /> r� <br /> Owner's Name ' � Phone <br /> Address ity <br /> Contractor's Name��` �+ �� License# Business Phone ®774 <br /> Contractor's Address Emergency Phone <br /> f Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes T�- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ nn,, <br /> REPLACEMENT❑ V <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r 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 I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ( ❑ GEOPHYSICAL Surface Seal Inst d By: <br /> PUMP INSTALLATION: Contractor Or 5E&g2e <br /> 3 Type of Pump H.P. C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP R&PAl State Work Done "t""' *" <br /> DESTRUCTION OF WELL: Well Diameter A proximate Depth C <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:"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 issued, I shall employ persons b'pct to workman's compensation laws of California." <br /> ! I vfIl call for Grout Ins i n i r t gro in an -final inspecti n. <br /> Signed ille: Date <br /> (Draw Plo Ian n Reverse Side) <br /> 4 FOR DEPARTMENT USE ONLY <br /> 4. <br /> PHASE I <br /> Application Accepted By <br /> Date V O <br /> Additional Comments: <br /> Phase II Grout Inspection as t " aI I pection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 5 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 3 'may-I <br /> FEE 6 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER pO <br /> i d07)C1 <br /> ` Received by Date Receipt No Permit No Issuance Dat Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box ZOOS STOCKTOl 95201_ - <br />