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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. 3 <br /> -FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL _ t <br /> (COMPLETE IN TRIPLICATE) 2-0Li -j Vo,� •�pS�MATER QUALITY <br /> pa <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 Ordin nce No.1862 and the les an reg lal s of the San Joaquin Lgcal Health District. <br /> Exact Site AddressG(J. GB?�cP/C s <br /> —�t� ����� _.•EityJTown _�f <br /> Q"Nner's Name / Phone is <br /> Address City <br /> Contractor`s Name _,1� <br /> T, Lic nse# Wa / Business Phone ✓rte.=AL2 <br /> contractor's Address mergency Phone <br /> IsCertificateof Workman's Compensation In urance on File With SJLHD? Yes_ ___ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ _ { <br /> DISTANCE TO NEAREST: Septic Tank 400 Sewer Lines Pit Privy <br /> Sewage Disposal Field / )ry cesspool/Seepage Pit Other ; <br /> Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED USE <br /> TYPE OF WELL <br /> ii <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f/ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _Z60 Grp <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL { Surface Seal Installed By: a1� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done w� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C - <br /> Describe Material and Procedure <br /> s - <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. �b •`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 �4 <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 grall for a Grout Inspectio rior to grousing a d afinal inspection. <br /> Signed X Title: - Date: / <br /> (Draw PI Plan on Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted By Date <br /> Additional Comments: <br /> Pha 1 rout Inspection Phase IIJ/Final Inspection <br /> Inspection By Dat Inspection By y Date <br /> j <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> (� Y <br /> OTHER <br /> i <br /> OTHER <br /> Received by Date Receipt No. - Permit No. Issuance-Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16111 E.HAZELTON AVE.,P.O.60■2409 STOCKTON,GA 95201 } <br /> i <br />