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Applications Will E Piocessed When Submitter!Properly Completed. Be Sure To Sign The Application. `e <br /> FOR OFFICE USE: . APPLICATION <br /> /,0 (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County 00inang6 N 862 and the rules and regulations of the San Joaquin Local Health District. i <br /> Exact Site Address City/Town 7 <br /> Owner's Name Phone <br /> Address / City <br /> Contractor's NameP. Li ense# ZAR-'?scS_'f3usiness Phone 4, "1 <br /> Contractor's Address mergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El �f <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 V Dia. of Well Casing (ri <br /> 151 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing W I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout <br /> ❑ DISPOSAL — ❑ OTHER Other Information <br /> ElGEOPHYSICAL Y Surface Seal Install By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu m H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP RSA: 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 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 forwhich this <br /> permit is issued, I shall employ person§subiect to workman's compensation laws of California." ' <br /> I ill call for a Grout Ins p tion riovtd"' fang an a final inspection. <br /> Signed 4� r Title: <br /> ` . Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By_!� r/{�� <br /> - Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase II Final Inspection <br /> Inspection By Date Inspection 6y •4z�rt' ��Date <br /> .f=ee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Cl January 1 eceived By January 31 ❑ July 1 &Received By July 31 <br /> RiLLING REMITTANC $ REMIT <br /> BASE EXPLANATION AMOUNT{]UE CHECKED <br /> DATE DAT REMITTED <br /> _ AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> V{Y' V d <br /> PLUS <br /> PENALTY <br /> OTHER / /1��7tly f:iC`C/I C <br /> OTHER o`!/ <br /> CS c7 \�IZ. <br /> Received'by Date . . Permit No. Issuance Date Mailed" Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 5TOCKTON,CA 95201 <br /> ---- .. -- <br />