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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ <br /> I FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> I ENVIRONMENTAL HEALTH PERMIT ] %� <br /> t (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 application is <br /> f made in compliance with San Joaquin County-Ordinance No. 1862 anxi thy.rules and regulations of the San oaquin Local Health District. <br /> I Exact Site Address City/Town <br /> Owner's Name ''#` <br />+ - <br /> Address f, City' <br /> Contractor's Name License# 7/ Business Phone- <br />' Contractor's Address Emergency,Phone <br /> Is Certificate of Workman'sCompensation Ins ru ante on File With SJLHD? Yes ��� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ "_ DEEPEN ❑ RECONDITION❑ `; DESTRUCTION❑ <br /> WELL CHLORINATION ❑ -WELL ABANDONMENT;❑ OTHER ❑ PUMP INSTALLATION W: -- PUMP REPAIR IJ <br /> REPLACEMENT❑ J <br /> R � <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. 1 <br /> INTENDED USE TYPE OF WELL <br /> ,❑-, IINPWSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r �` <br /> L?DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing.,..! - 1 s <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth o Grout Seal`" i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY "'Type of Grout 't <br /> 11 DISPOSAL ❑ OTHER _a'� Other Information <br /> ❑ GEOPHYSICAL � '" r Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contract-6r F <br /> -,—'Type of Pump - -... H.P. <br /> PUMP REPLACEMENT: "s" ❑ State Work Done - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth 3 <br /> Describe Material and Procedure <br /> I hereby certify that Ihave prepared this application and that the work will be dond',in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> t <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit C <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 will for a Grout Inspection prior to grouting and a final inspection. z <br /> i <br /> Signed v .._ Title: Date: 3 �� <br /> (Draw Plot Plan on verse Side). <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: r <br /> r Phase II Grout"tnspection Phas II!_FJpaI Inspection <br /> Inspection By Date Inspection B''y Date <br /> Fee.Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE _ ,� _ REMIT <br /> DATE DATE REMITTED <br /> AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEAa <br /> LESS t. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> f <br /> L—al <br /> Rived by + - Date - Receipt No. Permit No.f Issuance to Mailed F Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 -i <br />