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'�Applicatlons-Wlfl Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> FOR OFFICE USE: _,.� � APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> I PUMP&WEL40/ <br /> L <br /> ENVIRONMENTAL HEALTH PERMIT ` <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe quinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San o i ty dinance No. 1862 and the rules a d regulations of the Joa uir Lo I Djtrict. <br /> Exact Site Address City/Town , <br /> Owner's Name & Phone ! <br /> Address City <br /> Contractor's Nam — License# Busi ss Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No AIII, <br /> TYPE OF WORK (CHECK): NEW WELL❑ . DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION;; 11 REPAIR❑ Y <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other s <br /> Property Line Private Domestic Well Public Domestic Well <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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION . ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sugece Seal Installed <br /> PUMP INSTALLATION: Contracto fit f7te—egnm <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter_ K Approximate Depth <br /> Describe Material and Procedure <br /> L <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 /> k 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-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 II all for a Grout inspection p or grow' and a final inspe <br /> Signed X Title: a� Date: <br /> (Draw Plat Plan on Reverse Side) <br /> G <br /> F�PEPAR ENT U ONLY <br /> PHASE Iq <br /> Application Accepted By Date 7 ?! <br /> Additional Comments: <br /> Phase II Grout Inspection Phase;111,Finalinspe_._c ,tion. <br /> Inspection By Date Inspection -y Date <br /> It -Z4- + -� 'C <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE - ❑ EACH ❑ January 1 &Received By January 331 Julfi1�& ived By July 31 <br /> - <br /> F <br /> - REMIT <br /> BASE EXPLANA ION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED `. AMOUNT <br /> FEE �✓� L� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y <br /> OTHER - <br /> } <br /> ,_ 9 <br /> Received by -- Date Receipt NoPermit No: Issuance Date Mailed Delivered <br /> . <br /> `APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2069. STOCKTON,CA 95201 <br />