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..= ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � ^ <br /> FJR OFFICE use: APPLICATION <br /> (For Non-Transferable;Revocable, Suspendable) <br /> r ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> ' (COMPLETE IN TRIPLICATE) WATER QUALITY <br />} Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliancewl SAP J a uin F!(puntrdin ce No. 1862 and the rules and regulations of the San Joaq L-Frcal He th District. <br /> r. Exact Site Address City/Town <br /> Owner's Name <br /> Address ` Phone <br /> City Qt <br /> Contractor's Name License Business Phon t <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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT 11 PUMP INSTALLATION 11PUMP REPAIR❑ <br /> s <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy i <br /> i <br /> Sewage Disposal Field <br /> g p Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL I ; <br /> Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Wel! Casing ' +` <br /> DOMESTIC/PUBLIC ❑ .DRIVEN Gauge of Casing <br /> fl— <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal �r <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ���tace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: 13 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth s <br /> Describe Material and Procedure <br /> I hereby certify that 1 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 the work forwhich this permit 1+ 1 <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 Grout Inspec on prior to grouting and a final inspection. <br /> Signed X J ri J�� � <br /> Title: �' rl.CJ7� � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE l FOR DEPARTMENT USE'ONLY <br /> Application Accepted Bvl�&q. Date <br /> Additional Comments: <br /> Phase It Grout Ins ecti ha a 111 Final Inspection c G� <br /> Inspection By tee a—�"+ Inspection By Date l�O� <br /> i <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B Januar <br /> Y Y 31 C1 July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REWTTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No -Permit No. Is uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPfES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.Box.2009 STOCKTON,Ck95201 <br />