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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TneApplication. <br /> F FOR-OFFJCI_USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 app <br /> licationis <br /> made in compliance with San Joaquin C u ty O dinance No. 1 62 d the rut s and regulations of the San Joaquin Local Health District. <br /> I Exact Site Address City/TownY <br /> Owner's Name PhoneAdd � <br /> ss City <br /> Contractor's Name License# �Isi e S Phone I <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensati Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> rTYPE OF WELL <br /> I INTENDED USE <br /> ❑ 1>0USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> E DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth Of Grout Seal <br /> ❑ CATHODIC PROTECTION { ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . <br /> ( ,Tyyp °f Pump H.P. �✓ <br /> PUMP REPLACEMENT: L'2 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work lorwhich 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 J <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will for a Grout Insoet9tio prior to gr uting and a final inspec' <br /> Signed X Title: Date: �Q <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY O <br /> r PHASE I Date�b_30_9 <br /> Application Accepted By <br /> E Additional Comments: <br /> Phase 11 Grout Inspection a III Final Inspection <br /> Inspection 8y Date Inspection By r Date, <br /> i. Fee Is Due: ❑ ANNUALLY (� PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &ReceivedREMIT <br /> UIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ! i Lq fl C) <br /> FEE <br /> LESS <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> � f <br /> k OTHER <br /> • OTHER <br /> ir - Iss ante, ate Mailed Delivered - <br /> ReceivedReceipt NOL No. _ <br /> 'APPLICANT- <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009' STO'KKTON,A952201 <br />