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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r� <br /> Application is hereby made tot an Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is D <br /> made in compliance w' Oagl Cou ty Ordinance No.1862 and the rules and regulations of the San J aquin,Local Health District. <br /> Exact Site Address 1 City/Town / i <br /> i <br /> Owner's Name Phone l <br /> Address City <br /> Contractor's Name 4 icense#�� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION LJ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank C7 Sewer Lines /400 Pit Privy 1 <br /> Sewage Disposal Field ` � Cesspool/Seepage Pit Other <br /> Property Line I/ Private Domestic Well ��6 Public Domestic Well <br /> INTENDED USE TYPE OF WELL 'q �D <br /> „❑,r INDUSTRIAL CABLE TOOL Dia. of Well Excavation_/�_ <br /> tz4 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �— <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �� 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f � _ N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth y <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 j <br /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the fallowing:"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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wi11 11 for a Grout In p'pttion print to grouting and a final inspecti <br /> Signed X Title: !✓ ' .T.T Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date G l7 <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph a 1.V Final In§pection <br /> Inspection By Da-te_ y —l�� 7 Inspection By JOV Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE <br /> BILLING REMITTANCE $ REMIT <br /> EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ef <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered- <br /> APPLICANT—RETURN <br /> elivere0APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK- <br />