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t _ 12 Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAppllcaIon. , <br /> FUiR�UFtICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT rr�� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY w <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is d <br /> made in cornpliance with San in Cou ty OrdinArtce No. 1862 and the rules and regulations of the San Join Local Health District. ) <br /> Exact Site Address City/Town el�-G <br /> Owner's Name ' Phone -3 —3ve, <br /> Address _ City <br /> Contractor's Name F t icense# '3eY��1 Business Phone 7 7 <br /> Contractor's Address Emergency Phone `e <br /> Is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION IJDESTRUCTION E] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ / I <br /> DISTANCE TO NEAREST: Septic Tank% Sewe!,Lines Pit Privy <br /> Sewage Disposal Field <br /> 1-1~ 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 14 DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r <br /> ❑ <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 4S a/ <br /> Type of Pump �/ H.P. <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 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 w"I call for a Grout Inspection prior to grouting and a final inspectlo� <br /> Signed X ` Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Pltase 11 Grout Inspection `r� P I inal Inspection <br /> Inspection By Date 3 13)$ Inspection By Date <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 /> FEE: C� <br /> LESS T - <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance ate Mailed Deli e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HE H PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST C A 95201 <br />