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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TileApplication, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with Sir JgagLp Cg�ty Ordinance N 1862 nd the rules nd regulations of the.San Joaquin Local Health District. <br /> Exact Site Address y f <br /> City/Town <br /> t <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name <br /> 4:±qzp License#` +�2` ?i�_ Business Phone ) <br /> Contractor's Address 9 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Ye No W <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDI ION❑ DESTRUCTIOrNN O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C1 OTHER 11 PUMP INSTALLATIOI PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Properly 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 <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t 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 persons subject to workman's compensation laws of California." <br /> N <br /> I will all for a Grout In ection prior to grouting and a final linspectiont <br /> Signed X <br /> s i��' Title: ' Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: <br /> Phase It Grout Inspection a anal Inspection <br /> Inspection By Date Inspection By �—6Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &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 /> EFEE <br /> �71 <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST4CKT4N,CA 95201 <br />