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v Applications Will Be Processed When Submitted Property Completed. Be SureToSign TheAppllcanon <br /> APPLICATION. <br /> FOR <br /> -OFFICE USE: i <br /> .. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL O <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br />� PLETE IN TRIPLICATE) <br /> IicationisherebymadetotheSanJoaquinLocalHAalthDistrictforapermittoconstructand/orinstalltheworkhereindescribed. Thisapplicationis <br /> made in compliance wi h 5gn irounty ance No. 1862 he rules and regulations of the San Jo quip Local Health District. <br /> Exact Site Address Z City/Town' <br /> Phone <br /> Owner's Na <br /> • - ity � <br /> Address <br /> '� License � Business Phone <br /> Contractor's Nam <br /> Contractor's Address] rgency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Cl OTHER ❑ PUMP INSTALLATION UMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <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 /> 191 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION fir, ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> C1 GEOPHYSICAL ce Seal Insta d B � <br /> PUMP INSTALLATION: Contract 0S <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> ng:'kl certify that in the performance of the work for which this permit <br /> Home owner or licensed agent's signature certifies the 1ollawi <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i Contras is hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> k perm; �ssued, I shall employ persons s jest to \it rkman's compensat" n aws of California." <br /> f I w• cal for a Gro ?I e t' n pri routing , d a final inspect s <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPA TMENT USE ONLY c? <br /> PHASE 1 Dat `�d <br /> Application Accepted By <br /> i Additional Comments: <br /> a Grout Inspection Phase "n Inspection <br /> I Inspection By <br /> Date Inspection By Date <br /> '1 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> ffREM IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE / <br /> LESS <br /> ! PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER T <br /> OTHER <br /> Received by Date Receipt No. PC I i Issuance Date Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVI _�5 t\e) 1501 E.HAZELTON AVE.,P.O.Box 2009 STOC�TON,GA 95201 <br /> CES <br />