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FjApplications W111 Be Proce�ssd When Submitted Properly Completed. Be 5ui ,0 Sign The Application. <br /> APPLICATION.-.;. <br /> OR OFFICE. E: ;. - . . <br /> (For Non-Transferable; Revocable, Susperidable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforap, �mlttoconstruct and/or install the work.herein described.This application is <br /> _made in compliance with San Joagyin bounty O dinar No. 1Be n the rules and regulations of the San Joaquin-Local Health District. <br /> F ` City/Town f .. " "" '` <br /> r .- <br /> Exact Site Address • <br /> Phoneaq <br /> Name <br /> ClAddress City ¢ <br /> ' a Bu 'Hess Phoae <br /> Contractor's Name License I , <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 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> I REPLACEMENT❑ <br /> —DISTANCE TO NEAREST: Septic Tank Sewer tines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> as Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I ❑ D OMESTIC/PUBLIC 13DRIVEN 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. F <br /> k PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work bone <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 r <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> F11 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 for which this <br /> F�' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i l will call for a Grout InsRection prior to grouting and a final inspection. <br /> i <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> + FOR DEPARTMENT USE ONLY <br /> PHASE i ��t -_-_ d <br /> F'! Application Accepted ByDate <br /> Additional Comments: <br /> Phase 11 Grout Inspection h e l l incl lns'peclion 1 <br /> Inspection By <br /> Date Inspection 8y ; Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R ReceivedREMITuly 31 <br /> r <br /> BASE - EXPLANATION KILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F14 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> I <br /> f OTHER <br />