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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Applicationi h yma oheSanJoaquinLocalHealthDistrictforapermittoconstructand!orinstalltheworkhereindescribed.Thisapplicationis <br /> rade in co I Joaquin County Ord' <br /> ce No. 1852 and the rules and regulations of the San Jo�gttin Lac I ealth District. <br /> Exact Site Address ,zz,I• � _? City/Town 1 q L i <br /> Owner's Name F Phone - - 1 I. <br /> a <br /> Address City 14 <br /> Contractor's Name License Business Phone - ; <br /> Contractor's Address F � Emergency Phone 46 <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 ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ i �—� l <br /> DISTANCE TO NEAREST: Septic Tank �/ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line_/i�? Private Domestic Well Public Domestic Well <br /> INTENDED USE }� TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation t <br /> O'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9�'1RRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �G`(_ f91,� Y j <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P- - n <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 will call for a rout Inspectio prior t0 grouting and a final inspection. <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �4 <br /> Application Accepted ByDate <br /> Additional Comments: <br /> Pha ll out Inspection�f Phase III Final Inspection <br /> Inspection By D to�{ -e�y Inspection By Date <br /> Fee Is Due: ❑ AN PE i ❑ PER ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 3 343� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V _ <br /> Received by Date Receipt No. N-rrmW No. ss ante Pate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ZELTON AVE.,P.O.Box 2009 STOOCCKTTOON,CA 95201 <br />