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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sig The Application. } <br /> FOR OFFICE use: APPLICATION <br /> - C (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> F (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described,This application is <br /> made in Compliance with San Joaquin County Ordinance 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (,AJ, City/Town <br /> "Owner's Name �}.JL - ® <br /> Phone <br /> Address City <br />( Contractor's Name ►License Business Phone_ � I <br /> Contractor's Address t3File With SJLHD - <br /> — mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on ? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATIObi,.0 WELL ABANDONMENT ❑ 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 /> TENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ <br /> DOMESTIC/PRIVATE ❑ <br /> DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information tI <br /> ❑ GEOPHYSICAL Surface Seal Installed By: OO <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P j <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <br /> PUMP REPAIR: ❑ State Work Done I <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 Joa uLun�� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. q- . J <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: Date: �- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> I <br /> Application Accepted By Date <br /> Additional Comments: ) <br /> Phase If Grout Inspection IN Fin n tion <br /> Inspection By Date Inspection By ate -4F <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE F.' AMOUNT <br /> LESS <br /> '°`PRORATION <br /> PLUS-- <br /> PENALTY <br /> OTHER <br /> OTHER y <br /> C <br /> Iceived by Date Receipt No Issuance Date Mailed red <br /> t P Permil No- <br />�'`"PL(CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 S OCKTON,CA 95201 " <br />