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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 /> / ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) tom WATER QUALITY <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 <br /> made in compliance w' oagi.jD Cou ty Ordinance No.1862 and the rules and regulations of the San J aquin,Local Health District. <br /> Exact Site Address _ City[Town <br /> r <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name + Cr icense# -1-77 / Business Phone 0.4 1_19 Sr� <br /> Contractor's Address dJ 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 ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ < <br /> DISTANCE TO NEAREST: Septic Tank �DD Sewer Lines �r� Pit Privy <br /> Sewage Disposal Field ,+ Cesspool/Seepage Pit Other <br /> Property Lineaz Private Domestic Well_,:—r7 Public Domestic Well <br /> INTENDED USE TYPE OF WELL ,C .Z <br /> C1INDUSTRIAL CABLE TOOL Dia. of Well Excavation �� ASO c <br /> ADOMESTIC/PRIVATE DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Casing , <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal S 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information (J <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: ❑ 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 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 it for a Grout In p tion prior to grouting and a final inspecti <br /> Signed X Title: - Date: �- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Z, Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phas I Final to ection <br /> Inspection By Date �i1��l�- 7 Inspection By wic: Date <br /> ✓ <br /> fi" ll/ar I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT FER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> I':. <br /> Received by Dale Receipt No. Permit No. Issuance te Mailed Delivered� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCK- <br />