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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Fora OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendabie) <br /> PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) P (NATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health Qistrict. <br /> ►. Exact Site Address Z-07 -dzz City/Town <br /> Owner's Nam `7 <br /> e 0C ._ ��S��C Phone <br /> Address �—Z/ !-I City�T <br /> I Contractor's Name '? License Business Phone <br /> Contractor's Address U C�/ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Mr OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r.Y,< DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑' DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: - <br /> f PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter l Approximate De th <br /> Des ibe Material and ProcedureCIA <br /> LrI w a f� tv r <br /> I hereby certify that I have prepared this application and that the work will be doe in accordance with an Joaquin County COLce/k <br /> 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <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 /> s <br /> s. I will c II fora ut Inspection prior to grouting and a final inspection. �]/ <br /> Signed X }} Title: Date: <br /> . � (Draw Plot Plan on Reverse Side) <br /> FO DEPAR MENT USE ONLY <br /> PHASE 1 /J �G <br /> Application Accepted By �J �""" O Date <br /> Additional Comments: �Y <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date , Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE, $ AMOUNT DUE CHECKED <br /> DATE D TE REMITTED AMOUNT <br /> r <br /> FEEr <br /> ! LESS <br /> PRORATION <br /> PLUS .i e <br /> PENALTY <br /> OTHER D <br /> E . <br /> OTHER <br /> X-B. <br /> --7 g <br /> 1 Received.by Date f Receipt No Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTONl& <br />