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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR OFFICE USE: ' <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication is hereby made to theSan Joaquin Local Heatth District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wl_lh S JJ County inane 862 and the rules and regulations of the Saljpaquin Local Health District, <br /> Exact Site Address City/TownPho _ ' <br /> 9� <br /> Owner's Name City ' <br /> Address City <br /> Contractor's Name License# �- B siness ho <br /> i+ <br /> Contractor's Address ® Emergency Phone _. <br /> Is Certificate of Workman's CompensationIns ranee on File With SJLHD? Yes X No <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> S WELL CHLORINATION © WELL ABANDONMENT OTHERXPUMP INSTALLAT ONN 0 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 /> �r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1 ❑ 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. `J <br /> !, PUMP REPLACEMENT. ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate epth <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 subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> 1 <br /> Signed X Date: <br /> Jk <br /> g {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /`T <br /> Application Accepted By Dated�c) <br /> Additional Comments: <br /> Phase li Grout Inspection se III Fin <br /> Inspection By Date Inspection a e <br /> f <br /> Fee - <br /> Is Due: ❑ ANNUALLY El UNIT ❑ PER SITE El EACH ❑ January eceived January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> I - - BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LES F> <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> S OTHER <br /> Received by Date Receipt No. Permit No. Is ance ate - Mailetl Delivered <br /> � . APPL4CANl'—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 STOC!(TON,CA 85201 <br />