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Applications Will Be Processed When Submitted Properly Completecl. Sebure 10 bign 1neRppnsanvn. r <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ��� j � r AT R QUALITY <br /> Application is hereby madetotYfeSan Joaq in Local Healthstrictforapermittoconstruct and/or install thework herein described.This application is <br /> made in compliance with an o ui c +¢y Ordin nce cr 1862 and the rules and regulations of the San JjpAwin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address �''�� City <br /> Contractor's Name License#4­1-.1? Bu .n essp_hone. '`+�/ �ys <br /> low <br /> Contractor's Address ell Emergency Pho e <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �y <br /> PUMP REPAIR <br /> WELL CHLORINATION 13WELL ABANDONMENT 11OTHER 13PUMP INSTALLATION El `(�✓ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,LNDUSTRIAL 13CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: trState 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 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 /> I will call for a Grout Inspection prior to grouting and a final inspeciio <br /> Signed X Title: _ r � /lf_Olt _ Date:If <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 4 <br /> PHASE I / �_of �� <br /> Application Accepted By N Q �1 ��� Date <br /> Additional Comments: , <br /> Phase II Grout Inspection Ph a Fin I Inspect9n <br /> Inspection By Date Inspection By Date �l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ 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 /> FEF <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 'L / <br /> Received by Date Receipt No. —Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES.. _ 1601 E.HAZELTON AVE..P.O.Sox 2009 STOCKTo, CA,_ 01 <br />