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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure ToSign The Application. <br /> �7R OFFICE USE: <br /> / APPLICATION <br /> 14- <br /> - ' (For Non-Transferable, Revocable,Suspendable) <br /> 7 ENVIRONMENTAL HEALTH PERMIT PUMP&11VELL <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 isp <br /> made in compliance wi h 5a J aquin CountyOrdinance No. 1 an the rules a regulations of the San oaquip Local Health!DD''Is rict. <br /> Exact Site Address Q a _ City/Town 9 <br /> Owner's Name Phone <br /> E Address City <br /> Contractor's Name icense# Busi ess Phone <br /> Contractor's Address Emergency Phone <br /> 1 Is Certificate of Workman's Compensation Insuran a on File ith SiL D? Yes � No <br /> TYPE OF WORK {CHECK): NEW WELL M- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA <br />` REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ' 7,. y_ `ivy <br /> p Sewer Lines �' Pit Privy <br /> Sewage Disposal.Field t Cesspool/Seepage Pit Ot r ` <br /> Property Line Private Domestic Well Public Domestic Well <br /> I LADED USE TYPE OF WELL. <br /> �,C/ABLE,TOOL__ Dia. of Well Excavation „ � -�, <br /> ❑ _ PRIVATE ❑ DRILLED Dia. of Well Casing �r <br /> OMESTI /PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVE CK Depth of Grout Seal r <br /> ❑ CATHbDIC PROTECTION ❑ ROTA YO Type of Grout <br /> ❑ DISPOSAL ❑ OTHM Other lnformati <br /> ❑ GEOPHYSICAL Surface Sea stalled .Ay: I <br /> PUMP INSTALLATION: ontractor <br /> r <br /> _ ype of Pump j H P <br /> PUMP REPLACEMENT: 13 State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done 111 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth v^ <br /> Describe Material and ocedur T <br /> I hereby certify that I have prepared this plic ion nd at the ork'will tie done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulNn f th San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certi s t Ilowing:"1 certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in h anner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature 'ties the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons ject to workman's compensation laws of California." <br /> I will call for a Grout Ins fI n pIn o grousing and a-final inspec ' n. <br /> Signed X Title: } ,T~ <br /> Date: <br /> Draw Plot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> ApplicatitD <br /> on AcDate <br /> cepte y r *, <br /> Additional CO;m nts: <br /> Phase 11 rout Ins do V� <br /> Inspe n B �, Phaklll Final In Ipectla� = <br /> p y <br /> on By ate <br /> Fee I Ue: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 A <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ]j <br /> FEE 3 A <br /> t y <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i' <br /> OTHER <br /> F <br /> -v <br /> Received.by. Date Receipt No. Permit No. Iss ncc <br /> Dat <br /> Mailed Delivered <br /> ApPL1CAN E URN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVECES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 Delivered <br /> CA <br />