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cations Will Be Processed When Submitted Properly <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP &WELL j <br /> ENVIRONMENTAL HEALTH PERMIT # <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> IT Local Health District for apermit to construct.and/or install the work herein described.This application Is <br /> Application is hereby made to the San Joaqui <br /> rdinance No. 86 an rules and regulations of the San.JoaquinLocal Health District. <br /> made in compliance with San Joaquin County f <br /> City/Town <br /> Exact Site Address r <br /> Phone fi e <br /> Owner's NameCity _ G)1 <br /> Address l <br /> Contractor's Name _ License# 7 rf' � Business-Phone <br /> ��. , 1 r <br /> Contractor's Address � Emergency Phone No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes�( <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION 13 PUMP REPAIR <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER <br /> ❑ PUMP INSTALLATION <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> o Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL 11 CABLE TOOL Dia. of Wel! Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC 13 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 Installed By: Y <br /> PUMP INSTALLATION: Contractor H P <br /> f Type of Pump ^ " <br /> PUMP REPLACEMENT: State Work Done <br /> State Work Done ''��`� <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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-coniracti person <br /> signature certifies the following:"I certify that in the performance of the work forwhich this <br /> pcompensation laws of California." <br /> permit is issued, I shall employ persons subject to workman's <br /> I will call for a Grout inspection prior to grouting and a final inspec ' n. 7- <br /> Title: - Dater <br /> Signed X <br /> <aW Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY Cf� <br /> I PHASE I � Igo <br /> Date <br /> Application Accepted By J 011 <br /> Additional Comments <br /> Phase II Grout Inspection se III Final peate <br /> } Inspection By Date <br /> Inspection By .�-� ate yS <br /> Juiy 1 &R <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑.January 1 8 Received By January 31 ❑ Received uIy 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> f BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> cf�o a <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER _ <br /> .r '7-1 0 <br /> 14 Received Na Permit No. <br /> -Issuance Dale•., Mailed Delivered <br /> Received by Date _ - <br /> APPLICANT—.RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,+1601 E.HAZELTON AVE.,,P.O.Box 2009 <br /> STOCKTON,GA 95201 - <br />