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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR O"FICE USE: APPLICATION <br /> j <br /> (For Non-Transferable, Revocable, 5uspendable) 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 V <br /> made in complianceit San Joaquin County dinance No. 1 a d the rules and regulations of the San aquin Local Heal h District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone — <br /> Address . City 'r «- <br /> Contractor's Name ' a License#1 7-Z Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ' t <br /> TYPE OF WORK (CHECK): NEW WELL'R DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ l <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer tines Pit Privy �. <br /> Sewage Disposal Field li ? Cesspool/Seepage Pit Other <br /> Property Line Private Domestic`Well Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I$� DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> E]'CATHODIC PROTECTION ROTARY Type of Grout <br /> ,!❑ DISPOSAL ❑ OTHER Other Information .) <br /> r ❑ GEOPHYSICAL S rface Seal Installed By: <br /> i° PUMP INSTALLATION: Contractor <br /> Type of Pump <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 t <br /> is issued, I shall not employ any person-in such manner as to become subject to workman's compensation laws of California." <br /> i Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work Eorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I will <br /> call for a Grout Inspe tion prior io grouting and a final inspection. <br /> Signed X:_ � �._. Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I g\' <br /> Application Accepted By ` Date r ,r <br /> Additional Comments: <br /> Phase II Grout Inspection r P se III Final inspection <br /> - . inspection B r-.Date ' l _ lnspecti ate Z 3 <br /> Fee Is Due: [3ANNUALLY ❑ PER UNIT EYPER SITE 13EACH C3January 1 &Received By Janu ❑ July 1 &Received By July 31 d <br /> REMIT ti <br /> BASE EXPLANATION BILL{NG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> i OTHER <br /> r�. ' <br /> 1 OTHER <br /> ALO <br /> Received by Date Receipt No. - -Permit No. Issuance Date Mailed Deliver d r <br /> APPLICANT-RETURN ALL COPIES TO: _ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009- STC CKT CJKT , 95201 <br />